These are my health care successes:

(Directions: Please write a few sentences regarding your condition before treatment, and then a few sentences regarding your condition now after receiving the health care we provided.)
Name ________________________

1. Describe your condition. How long had you been suffering?  How did it start?
2. What previous unsuccessful steps had you taken to try to solve your problem?

3. How did you find out about Dr. _____________?

4. Describe what Dr. _______________  did to help you. ( Examination, x-ray, treatment program, etc.)

5. What did Dr. _______ tell you your problem was?

6. Describe your progress, your results , and the benefits you received.
7. How has your life been improved since coming to our office? What can you do now that you could not do before?
8. Words of encouragement for others who have similar problems.
Signature _____________________________ Date_________
I hereby give my permission to publish my success story in whole or in part: (initial) _______

Procedure for
Success Story
Questionnaire Form

When the patient is ready to write their “success story”, have her or him fill out this survey.

Then, you can re-type it and have them sign the new version. Type the following on the bottom of the newly retyped story. When you display the patient’s story, you can mention: “(Individual results vary. These accounts were obtained without remuneration and within HIPAA guidelines.)”  You may also want to check with your state association if you have any questions.

I hereby give my permission to publish my success story in whole or in part:
Signature _________________________________   Date:______________________