Wellness Form - Batya Prebor, Mercaz Briut

For people looking for help with general health conditions (non-women’s health, non-hormonal, non-reproductive).

First Name

Last Name

Mobile Phone

Birth Date

Gender

Relationship Status

Occupation

Height

Weight

Have you ever had acupuncture before

How did you hear about us?

Name of doctor or friend that referred you

Describe what you would like us to help you with

How long have you had this problem?

What types of treatment have you or are you receiving for it?

Recently the condition has:

Not Changed Worsened Improved

What makes it worse?

What makes it better?

List medications, supplements you're taking (or enter "none" if none

List any major injuries or surgeries and when they took place (or enter "none" if none

Anything else you think we should know about the problem you are seeking help with

List known food or drug allergies (or enter "none" if none):

Energy level is generally

Check all that apply

Energy fluctuates a lot during the day Frequent sleepiness after meals Sudden burst of Energy in the evening Very tired in the moring

Mood is generally

Weight

Body temp sensation

Bowel Habits

Sleep is:

Check all that apply to sleep:

Bedtime

Wake time

Number of times you wake during the night

Describe time and types of foods you eat for breakfast (e.g. eggs, oatmeal, 7am)

Describe time and types of foods you eat for lunch (e.g. Sandwich, salald, 12 noon)

Describe time and types of foods you eat for supper (e.g. chicken, rice, vegetables 7 pm)

Describe time and types of snacks you eat:

General Intake Form