Wellness Evaluation Form

Patient Introduction

First name

Last name

Date of Birth

Month

Day

Year

Address

Phone

Email

Marital Status

Occupation

Current Primary Care Physician/Location

Initial Consultation

Main Complaints

List your top 4 Concerns/Complaints

How long have you suffered with these problems?

Any other concerns/complaints

Would you like improvement with any of the following?

Digestion: Reflux, Gas, Constipation

Sleep: Falling or staying asleep

Sense of Well Being

Energy

What have you tried doing to resolve this problem that DID NOT work?

Have you become discouraged or stressed about handling this problem?

When your problem is at its worst, how does it make you feel?

How does this problem interfere with the following areas in your life?

Work:

Family:

Hobbies:

Life:

When your problems are at their worst, how much older does this make you feel?

Do you know how this problem may have started?

What effect does this have on your body functions?

Are you visiting us to:

Resolve my immediate problem

Life style program for optimized living

Both

Other

How did the previous methods work for you?

Where do you picture yourself being in the next 3-5 years if this problem is not taken care of? Please be specific.

If we were to sit down and discuss your life 3 years from now and look back at today, what would have to have happened for you to be happy with your progress?

Please take your time and don't sell yourself short! Include anything that is part of your happiness; whether it's your health, family, work, finances, travel, marriage or bucket list.

What potential barriers do you foresee that would prevent these things from happening?

Do you feel it is possible to eliminate or prevent these potential barriers?

What are your strengths that will enable you to accomplish your goals?

Rate on a scale of 1-10:

How important is it for you to resolve your health concerns?

0 - Not important, 10 - Very Important

Do you feel that you are coachable and would enjoy a mentor in helping you?

0 - I am not coachable, 10 - I am very coachable

Are you prepared to make the appropriate lifestyle changes that may be necessary in order to achieve your goals?

0 - No, I am not ready, 10 - Yes! I am ready!

Thank you for taking the time to fill this out.

All information will be kept confidential with your provider.