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Optimize your health and heal your body

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Referred by:

What do you hope to achieve in your visit with me?

If you had a magic wand and could erase 3 problems related to your health, what would they be?

Have you made the decision to change? To do what it takes to reach your highest level of wellbeing?

List up to 5 things that you have been unable to do as a result of your present level of health and/or symptoms. Please be very specific.

Are there any other health goals you want to achieve? Please be very specific.

In order to get the result you desire, how willing are you to do the following: (5 stars being highest)

Significantly modify what and how you eat?

12345

Perform laboratory assessments that include collection of blood, urine, stool, and/or saliva?

12345

Take several nutritional supplements each day?

12345

Keep a detailed record of everything you eat each day?

12345

Modify your lifestyle (e.g. work demands, sleep habits, environment)?

12345

Practice relaxation techniques daily?

12345

Engage in exercise 2 days a week ?

12345

Have periodic lab tests to assess your progress?

12345

How confident are you of your ability to organize and follow through on the above health related activities?

12345

If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to fully engage in the above activities?

At the present time, how supportive do you think the people in your household will be to your implementing the above changes?

How much ongoing support and contact (e.g. telephone, email correspondence) from your professional staff would be helpful to you as you implement your personal health program? (5 being the need for more frequent contact)

Are you ready to invest at least $99 in your health?

Yes

No

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In order to get the result you desire, how willing are you to do the following: (5 stars being highest)

Thank you for taking a few moments to complete these questions and I look forward to speaking with you at your upcoming appointment.