MedHealth 360 Assessment

MedHealth 360 - The Premier Wellness Center
in Northern Virginia

Our staff looks forward to meeting you and discussing your goals. We strive to keep our appointments on time as scheduled. Prior to your appointment, we encourage you to fill out the patient forms that are located on this website so you can accelerate your check-in process. Please fill out this form as honestly and accurately as possible. You have a right to choose not to disclose any information requested in this form and can instead choose to discuss it privately with your doctor/assessor. Please note that your doctor/assessor and staff will see your responses to these questions and this information will become an official part of your medical record. Your information is confidential and will not be disclosed to third parties without your consent. This information will be used to help meet your healthcare needs as well as to allow us to identify any potential gaps in care in our clinic. We strive to provide the best healthcare possible, and we appreciate your assistance in this process.

  • Wellness Screening

  • 1 = Never ; 2 = Mild (Some Days) ; 3 = Moderate (Most Days); 4 = Severe (Everyday)
  • 0-40: Fairly Healthy; 40-60: Some Hormonal Imbalance is Likely; 60 and above: Deficiency is Probable
  • Top 5 Main Concerns:

  • Answer those that apply to you:

  • Energy

  • Sleep

  • Sexual Satisfaction

  • Bathroom Habits

  • Urinary Incontinence

  • Hair skin nails

  • Hormonal Imbalances

  • Stress

  • Immunity

  • AutoImmune

  • Joint Pain

  • Mental Clarity / Brain Fog

  • Tobacco / Drug Use

  • Anxiety

  • Physical Activity

  • Body Composition

  • Dietary

  • Enter Full Name
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.


Refer a friend and you will BOTH receive $50 in Dollar Discounts.