Patient Survey

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

MHS will keep your information in strict confidence. This survey will be used only to help our MHS 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 MHS 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 symptoms, 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 MHS 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?

Expect Great Results