Custom Wellness
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  • Home
    • Disclaimer
  • Espanol
    • Carolina C'Nol - Sobadas & Especialista en Técnicas de Salud Natural
    • Connie Kelly - Practicante de salud natural
  • Our Team
    • Connie Kelly - Natural Health and Nutrition
    • Carolina C'Nol - Body Work & Herbal Health
    • Mark Balcer - Energy Touch Practitioner, Reiki Master & Reflexology
  • Services
    • Services
    • Wellness Visits
    • Acupuncture
    • Body Work
    • Massage Therapy
    • CranioSacral Therapy
    • Light Healing Touch
    • Reflexology
    • Nutritional Therapy
    • Iridology
  • Workshops
  • Reviews
  • Contact
    • Contact
    • Hours
  • Book an Appointment
  • Blog
  • Careers
  • Sign-up

Symptom Survey


    Assign a number to the symptoms that you experience in the last 2 weeks using the following scale. (1) for MILD symptoms, (2) for MODERATE symptoms, and (3) for SEVERE symptoms. LEAVE BLANK IF IT DOES NOT APPLY TO YOU!

    Group 1

    Group 2

    Group 3

    Group 4

    Group 5

    Group 6

    Group 7-A

    Group 7-B

    Group 7-C

    Group 7-D

    Group 7-E

    Group 7-F

    Females Only

    Males Only

    Please list your 5 main health complaints, in order of importance:

Submit
If you are a new client, after filling out the Symptom Survey form, please visit the New Client Orientation page.

Custom Wellness serves:
Sedona, AZ
​Holland, Michigan
West Michigan Lakeshore
Anywhere in the US online.

(616) 294-7427
english and español
​Email



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