Wellness Assessment | Well Health Acupuncture

01

About you｜基本资料

Name｜姓名 Phone｜电话 Email｜邮箱 Age group｜年龄段* Gender｜性别*

02

Primary wellness goal｜主要目标

Reduce pain
减轻疼痛 Improve sleep
改善睡眠 Manage stress
压力管理 Improve digestion
改善消化 Support women’s health
女性健康支持 Improve body composition
改善身体成分 Understand glucose patterns
了解血糖模式

03

Main concerns｜主要困扰

Duration｜持续时间*

04

Body signals｜身体信号

Cold & heat tendency｜冷热倾向* Bowel condition｜大便情况* Thirst condition｜口渴情况* Sleep condition｜睡眠情况* Current condition (for female only)｜目前状态（女性填写）

05

Wellness scores｜健康评分

0–10 per item. For sleep/energy/digestion/readiness: 0 = very poor, 10 = excellent; for stress/pain: 0 = none, 10 = severe.｜每项 0–10 分；睡眠/精力/消化/意愿：0 最差，10 最好；压力/疼痛：0 无，10 最重。

Sleep quality｜睡眠质量 5 Energy level｜精力 5 Stress level｜压力 5 Digestive comfort｜消化舒适度 5 Pain severity｜疼痛程度 5 Readiness to improve health｜改善健康的意愿 8

06

Tongue photos｜舌头照片

Upload tongue photos (multiple allowed)｜上传舌头照片（可多张）

You can upload up to 5 files.｜最多可上传 5 张。

Tips｜拍照提示：natural light/white light; no filter; tongue relaxed and naturally extended; clear focus; capture the root of the tongue when possible.｜自然光/白光；无滤镜；舌头放松自然伸出；对焦清晰；尽量拍到舌根。

07

Medication & notes｜用药与补充

Currently taking any medicine or supplements?｜目前是否在服药/保健品？* Medicine name｜药品名称 Additional notes｜补充说明

08

Next step｜下一步

Interested in InBody assessment?｜是否希望做 InBody 评估？ What would you like to do next?｜您希望下一步

Your responses will be sent securely to our clinic team.｜您的填写内容将安全发送至诊所团队。