Align360™ Wellness Questionnaire

This questionnaire helps us understand your wellness goals and background so we can personalize your Align360™ visit.

This questionnaire helps our team better understand your health, lifestyle, and wellness goals before your Align360™ visit. Your responses allow us to personalize recommendations and make the most of your appointment. It takes approximately 5–7 minutes to complete, and all information is kept confidential. If you’re unsure about any question, answer to the best of your ability—there are no right or wrong answers. *

SECTION 1 — Body & Demographic Information

Age (copy) *

Sex / Gender (copy) *

Male

Female

Prefer not to say

Height (copy) *

Weight (copy)

What is your PRIMARY wellness focus right now? Select one.

If other:

What are your top three wellness goals?

SECTION 2 — Medical Background

If you selected ‘Other,’ please add it here:

Family Medical History (Optional)

Do you currently have a PCP (Primary Care Physician)?

Yes

SECTION 3 — Medications & Supplements

Do you currently take any prescribed medications? *

Yes

I don't know

If you answered yes to taking any prescribed medication, please list the medications name, dosage, and frequency.

Include medications name, dosage, and frequency

Do you take any over-the-counter supplements or IV therapies? *

Yes

I don't know

If you answered yes to taking any over-the-counter supplements or IV Therapies, please list the name, dosage, and frequency.

Include name, dosage, and frequency

Allergies or Sensitivities

SECTION 6 — Health Goals

Other (Write other health goals here)

Additional Goals

Thank you for completing the Wellness Assessment Questionnaire!

The Align360™ Wellness Assessment and related forms are for educational wellness purposes only and do not constitute medical advice, diagnosis, or treatment. Robinson Chiropractic and Wellness Center does not provide medical services. Please consult a licensed medical physician before beginning any supplement, IV therapy, or other health-related program.

Align360™ Wellness Questionnaire

SECTION 1 — Body & Demographic Information

SECTION 2 — Medical Background

SECTION 3 — Medications & Supplements

SECTION 4 — Lifestyle & Activity

SECTION 5 — Nutrition & Diet

SECTION 6 — Health Goals

SECTION 7 — Symptoms & Wellness Indicators

Thank you for completing the Wellness Assessment Questionnaire!