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New Patient Questionnaire

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Online Health Survey

Please fill out survey and receive a free 15 min evaluation (a $60 value)

OHS will keep your information in strict confidence. This surevey will be used only to help our OHS practitioners determine the causes of your health problems and see if we can help you to become healthier, happier and more balanced.

PURPOSE: To gain insight about any health concerns you have and to see if the practitioners at OHS can help you.

Please fill out the following information and click the “Submit” button at the bottom of the form when you are done. Thank you!

*Your name:	Your age:	*Home phone:
	Cell phone:	Work phone:
Address:	City:	State/zip:	/
Occupation:	How many hours do you work each week?
Email:

1. Check off any of the following symptoms you have experienced in the past six months:

Of the above symtoms, which bothers you the most?

How long have you been bothered by the condition?

Describe how it feels or affects you when it is at its worst?

2. Does this cause you to be:

Moody Irritable Anxious Depressed Interrupted sleep Restricted daily activities

3. Does this affect your work?

Decision making Poor attitude Decreased productivity Feel exhausted at the end of the day Unable to work long hours Poor concentration

4. Does this affect your life?

Lose patience with spouse or children Restricted household duties Hinders ability to exercise
Interferes with ability to participate in hobbies

If you checked any of the above items, your organs are probably not functioning as well as they could, and your energy is probably not flowing as smoothly as it could.

Would you like to get rid of the problem? Yes No

If your answer is Yes, there are several alternatives available to you. Please check the item most appropriate for you:

I would like to come in to the office for an initial free 15 min quick assessment to see if the practitioners at OHS can help me.

I would like to come in to the office for a full new patient 1.5 - 2 hr assessment, extensive nutritional consultation, acupuncture treatment, and discuss Chinese herbs and/or supplements (if needed).

I would like the acupuncturist to call me to discuss my health problem before making an appointment.

Would you like to schedule an appointment? Yes No

If you prefer, feel free to call us directly at 919-286-9595

How did you get to our website? Friend, search engine (which?)

We have morning, afternoon and evening times available on various days. Which time of day will work best for you?

Please enter the above word here:

Expect Great Results