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Re-evaluation2019-05-21T03:25:59-04:00

Wellness care re evaluation

  • Fields marked with an * are required
  • Date Format: MM slash DD slash YYYY
  • Please enter a number from 0 to 10.
  • 6. What are your current health goals or concerns?
  • Please enter a number from 1 to 5.
  • *Rate each of the following symptoms based on your typical health profile.
  • Point Scale: 0—Never or almost never have the symptom 1—Occasional, effect is not severe 2—Occasional, effect is severe 3—Frequent, effect is not severe 4—Frequent, effect is severe
  • Head

  • Head / Eyes

  • Ears

  • Nose

  • Skin

  • Heart

  • Lungs

  • Other

  • Digestive Tract

  • Joints/Muscles

  • Weight

  • Energy/Activity

  • Mind

  • Emotions

  • Menstruating Women Only

  • All Women

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