Follow-Up Survey

You will receive your free eBook, "Maintaining Your Health", upon completion of this form.

Thank you for taking the time to complete our follow-up survey. Your valuable feedback will help us continue to improve our care.

This online form allows you to:

• Complete online - you can submit your response securely online
• Save - Upon saving, you will receive an emailed link to return to the form and complete it at your leisure
• Print - you can print and return the form via email, fax, or postal mail, if you prefer

You may download a print version if you prefer:

When filling out this form, please let us know:

• Any changes you have experienced since therapy
• Any difficulties you are still experiencing
• Any additional questions or comments you want to share with us

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First Name:
Last Name:
Email:
Zip:

Follow Up Form

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Section 1 - Section 2 - Section 3 - Section 4 - Section 5 - Section 6

Section 1: Personal Information

Name First Last	Home Phone - (###) - ### ####
Email	Cell Phone - (###) - ### ####
Contact Preference HomeCellWorkEmail	Work Phone - (###) - ### ####

• Address
  Street Address
  Address Line 2
  City
  State / Province / Region
  Postal / Zip Code
  Country



• Clinic location	Gainesville, FL Irvine, CA Woodbridge, VA
  Date of previous treatment
  Hours of therapy received




I Recieved treatment for:
Pain	Infertility	Obstruction	Adhesions		Specific conditions:



• What medical changes have you had since therapy? (surgery, trauma, infection, disease, fall, accident, etc.)

Section 2: Pain Improvement

Headache	Neck	Back	Abdomen	Intercource	Migraine
Shoulder	Tailbone	Pelvis	Ovulation	Menstrual

Please describe your level of pain improvement since therapy. The above list is for reference.

Pain in My is

Pain in My is

Pain in My is

Pain in My is

Details/Comments:

Section 3: Digestive Function Improvement

• Using a scale of 1 to 5:
  1 - No Improvement
  2 - Little Improvement
  3 - Some Improvement
  4 - Good Improvement
  5 - Great Improvement
  


• Please describe your level of digestive improvement in the following areas:

  Digest solid food		Pain with bowel movements
  Nausea after eating		Diarrhea
  Vomiting after eating		Digestive spasm
  Constipation		Borborygmi (bowel sounds)
  		Overall Digestion

Details/Comments:

Section 4: Sexual Function Improvement

• Using a scale of 1 to 5:
  1 - No Improvement
  2 - Little Improvement
  3 - Some Improvement
  4 - Good Improvement
  5 - Great Improvement
  


• Describe your level of improvement since therapy in the following areas of sexual function:

  Desire		Satisfaction
  Arousal		Orgasm
  Lubrication

Details/Comments:

Section 5:Female's Fertility Outcomes

Males skip to Section 6

I am now pregnant

Due date:

Comment

Became pregnant Number of pregnancies: Dates

Delivered Name(s), birth date(s):

Miscarried Dates:

Ectopic Dates:

Chemical (HCG but no heartbeat) Dates:

I have not yet become pregnant I am no longer trying to become pregnant

Became menopausal Date (approximate):




Date started cycle/medications: Transfer date: N/A




Egg type:	fresh	Results:	Pregnancy
	Frozen		Miscarriage
	Non donar		Ectopic
	Donor		Chemical Pregnancy(HCG but no heartbeat)
			Did not become pregnant.




Date started cycle/medications: Transfer date: N/A




Egg type:	fresh	Results:	Pregnancy
	Frozen		Miscarriage
	Non donar		Ectopic
	Donor		Chemical Pregnancy(HCG but no heartbeat)
			Did not become pregnant.




Tube(s) cleared after therapy:	Left	Right	N/A
Diagnosed by:	HSG	Laproscopy	Laparotomy
Hydrosalpinx cleared after therapy:	Left	Right	N/A
Diagnosed by:	HSG	Laproscopy	Laparotomy


Details/Comments:

Section 6: Contact

• Clear Passage Physical Therapy always keeps your identity confidential.

May we call you to share your experience with potential patients?	YesNo
May we call you to share your experience on a condition related forum?	YesNo
May we call you to share your experience with the media?	YesNo



• Please use the space below to note your story, comments, and/or questions.