595 Elm Place, Suite 208
Highland Park, IL 60035

847-681-8821

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Wellness Patients Forms

All Wellness Patients need to fill out the Nutritional Assessment Questionnaire.

NOTE: Please read the instructions and follow them. Each question MUST have it’s own answer. For example, even if the answer is “0” for the entire section, you will need to circle each question separately. Otherwise we are not able to score this questionnaire accurately.

Coming in for an Acupuncture Consultation?

If you are coming in for an acupuncture consultation, you will also need to fill our one of these two forms.

1) If you have mainly neck and back pain fill out the Functional Rating Index. Click Here for the Functional Rating Index.

2) If you have general pain or any pain syndrome fill out the General Pain Index. Click Here for the General Pain Index.

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595 Elm Place, Suite 208
Highland Park, IL 60035
847-681-8821