Patient Application Questionnaire
Step
1
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4
Let's start with your contact information.
Your information will be used
only
to contact you via text message and email regarding becoming a patient.
We're committed to your privacy. For more info, check out our
privacy policy
.
First Name
Last Name
Email
Phone Number
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Next
What are your health and wellness goals?
If working with us is a success, describe what would your life would be like a year from now.
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Next
How would you describe your current overall health?
Give us a general idea of how you feel about your health right now.
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Next
What obstacles are keeping you from living your fullest life?
Reflect on anything that may be limiting your day-to-day activities, wellness, or overall life satisfaction.
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Next
How do you manage your current health concerns?
Let us know what strategies or treatments you are currently using to manage your health.
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Next
Lastly, what are you looking for help with?
Select all areas you wish to improve so we can align our care with your health objectives.
On desktop, hold Ctrl (Windows) or Cmd (Mac) to select multiple fields.
Energy
Sleep
Exercise/Movement
Diet/Food Choices
Focus/Brain Function
Gut Function
Meal Planning
Mood/Anxiety
Weight Loss
Metabolic Health
Hormone Optimization
Anti-aging/Longevity
Managing Stress
Cancer Prevention
Alzheimer's Prevention
Cardiovascular Disease Prevention
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