Bey Acupuncture Assessment

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Welcome

Please take the time to fill out this short questionnaire, so that we can get you an appointment with Dr. Bey. If you have been treated before by Dr. Bey, then you will quickly be rerouted to the booking page. If you have not been seen by Dr. Bey before, the information requested is quite necessary to do so.

33Questions

1
Bey Acupuncture does not and will not share the following information with any third parties. All information gathered is used to create an accurate patient profile. Please answer as accurately and honestly as possible, so that we may direct you to the right services. Do you agree to these terms? * This field is required.Questions touch topics around mental health, physical health, and lifestyle.
YESNO
2
Name* This field is required.
First Name
Last Name
3
Date of Birth* This field is required.
Date
Month
Day
Year
4
What Gender Do You Identify As?
Male
Female
Non-Binary
Prefer Not To Say
5
How did you hear about Bey Acupuncture?
Referral
Online
I've been treated by Dr. Bey in the past
Other
6
How much do you know about the services offered at Bey Acupuncture?* This field is required.
I've been told what treatment I should get.
I know, but I'm curious to know what other services may benefit me.
I don't know.
7
What Brought You to Bey Acupuncture?
Physical pain or discomfort
Spiritual Guidance
Mental Wellness
Life Management
8
Which would you say your condition falls under?Choose all that apply
Neurological
Cardiology
Gastroenterology
Respiratory
Urinary
Sleep
Reproductive Male and Female
Pain
Endocrine
Musculoskeletal
Not Applicable
9
When Do You Notice Your Condition Most?Please choose which time during the day, you experience your condition.
3am-7am
7am-11am
11am-3pm
3pm-7pm
7pm-11pm
11pm-3am
10
How would you describe your overall mood?
Happy
Angry
Sad
Fearful
Worried
Anxious
Confused
Moderate
11
On a scale of 1-10, how would you rate your level of energy?1 being low, 10 being high
12
During what times of the day, do you feel the most energized?* This field is required.Choose all that apply
11am-3pm
3pm-7pm
7pm-11pm
11pm-3am
3am-7am
7am-11am
13
Do you suffer from lack of sleep?* This field is required.
YESNO
14
When do you get the most sleep?* This field is required.Choose all that apply
11am-3pm
3pm-7pm
7pm-11pm
11pm-3am
3am-7am
7am-11am
15
Do you suffer from anxiety and/or depression?* This field is required.Please answer honestly, so we can provide the best service for you.
YESNO
16
Have you had thoughts of harming yourself or others? * This field is required.
YESNO
17
Do you get treatment from a therapist or psychiatrist? * This field is required.
YESNO
18
On a scale of 1-10, how would you rate your physical health?* This field is required.1 being poor, 10 being superb.
19
Do you suffer from physical pain or discomfort?* This field is required.
YESNO
20
Which best describes how your pain or discomfort manifests?* This field is required.
Dull
Acute
Throbbing
On and Off
Circumstantial
21
Which are applicable to the conditions you are suffering from?* This field is required.Select all that apply
Neurological
Cardiology
Gastroenterology
Respiratory
Urinary
Reproductive
Endocrine
Musculoskeletal
Liver
22
How would you describe your appetite?* This field is required.
Often Hungry
Sometimes Hungry
Rarely Hungry
Never Hungry
23
How would you describe your thirst?* This field is required.
Often Thirsty
Sometimes Thirsty
Rarely Thirsty
Never Thirsty
24
How would you describe your sense of temperature?* This field is required.
Always Hot
Always Cold
N/A
25
Do you participate in any of the following activities?* This field is required.Select all that apply
Yoga
Reiki
Massage
Yoga
Sound Bowl Therapy
Spiritual Cleansings
N/A
26
How often would you say you participate in those activities?* This field is required.
Weekly
Bi-Weekly
Monthly
Quarterly
Yearly
N/A
27
How often do you get to escape from stress or go on vacation?* This field is required.
Weekly
Bi-Weekly
Monthly
Quarterly
Yearly
N/A
28
On a scale of 1-10 how healthy would you say your diet is?* This field is required.1 being very unhealth, 10 being incredibly healthy
29
Do you have any of the following diet restrictions?* This field is required.
Paleo
Keto
Vegan
Vegetarian
Gluten-Free
Lactose-Free
Raw Veganism
N/A
30
How often do you eat out?* This field is required.
Daily
Weekly
Bi-Weekly
Monthly
Quarterly
Yearly
N/A
31
When would be the best time to contact you? We will try and get speak with you the day of, to discuss your results!
32
What's a good phone number to contact you on?* This field is required.
Area Code
Phone Number
33
EmailBy sharing your email and selecting submit, you agree to subscribing for future promotions and updates, regarding to Bey Acupuncture.
example@example.com
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