Wellness Evaluation Form

Thank you for attending our dinner presentation and deciding to take action to move forward and achieve your health goals. Please fill out this wellness intake form, the patient intake form, the metabolic assessment form, and the neurotransmitter assessment form. Be sure to submit them before your wellness consultation, so Dr. Dae can review them and create a wellness plan for you.

Name *
Name
Phone Number *
Phone Number
Address *
Address
Date of Birth *
Date of Birth
Would you like improvement with any of following? *
Are you here visiting us to: *
How have you taken care of your health in the past? *
What are you afraid this might be or will be affecting without change? Please circle *
Are there any health conditions you are afraid this might turn into? *
What would be different or better without this problem? Please check *
1 is considered lowest and 10 is considered highest on the scale.
1 is considered lowest and 10 is considered highest on the scale.
1 is considered lowest and 10 is considered highest on the scale.

Please also take a moment to complete the Patient Intake Form.

Thank you!