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First Name

Last Name *

Your Best Email Address *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone *

What main health challenge you would like to overcome? *

Why is this important to you? *

What do you feel are the biggest obstacles preventing you from reaching your health goals? *

What is motivating you to invest into solving this health challenge? *

Do you take direction well? *

Is your family supportive of your decision to get well? *

What qualities are you looking for in partnering with a practitioner? *

What other types of practitioners have you worked with before? *

Functional Medicine PractitionerNaturopathic DoctorNutritionistMedical Doctor Medical SpecialistOsteopathChriopractorPsychotherapistTraditional Chinese MedicineMassage TherapistPersonal TrainerOther

What functional lab tests have you previously done? *

Comprehensive Digestive Stool TestOrganic Acids TestHormone TestingHeavy Metals TestMedical SpecialistGenomic or Nutrigenomic TestingNoneOther

Given that you have tried other methods previously, what would you like to do differently this time? *

In order to improve your health, how willing are you to make the changes required? (this includes diet, lifestyle, taking supplements, mindset, etc) *

How much do you spend each month on natural therapies, practitioners and supplements?

Is there any other information you feel is important?

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