assessment | One Body Acupuncture

Name

Last name

Date of Birth

Your email*

Phone:

Message*

Preferred Contact Method:

Phone

Email

Text

Other:

Overall Health Rating: (Self-assessment)

Excellent

Good

Fair

Poor

Medications & Supplements: (List all current medications & supplements taken regularly)

Do you follow a specific diet?

Yes

No

(If yes, please specify:

How many glasses of water do you drink per day?

Do you consume caffeine?

Yes

No

(If yes, how often? ___________ )

Do you consume alcohol?

Do you exercise regularly?

Yes

No

(If yes, what type and frequency?

I'm interested in the selected Services & Therapies:

Acupuncture

Facial Rejuvenation Therapy

Nutritional Counseling

Herbal Medicine & Supplements

Stress Management Techniques

Sleep Optimization Plan

Detoxification & Gut Health Protocol

Movement & Exercise Recommendations

Other

Indicate Other Services & Therapies:

Client Agreement & Acknowledgment*

I understand that this assessment is for informational purposes only and does not replace medical advice.

I consent to receiving recommendations based on my responses.