Date of Birth*

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What are your top 3 challenges that you would like us to help you overcome?*

Why are these health goals important to you?*

What is stopping you from accomplishing these goals?*

If you were to wake up tomorrow without these challenges, how would your life be different?*

What are the top factors that motivate you to invest in these problems?*

Do you have a strong support system to help you in this journey? (e.g., family, friends, significant other)*

How coachable do you feel you are?*

What are the characteristics you value in a doctor-patient partnership?*

How do you best learn? (e.g., reading materials, videos, podcasts)*

If other, please describe*

Considering your past treatments, what would you like to improve or do differently moving forward?*

Are you willing to do what is necessary to improve your health (dietary changes, lab testing and/or lifestyle modifications)?*

Are you willing to invest in a personalized health plan that would address your health and wellness goals and have long lasting effects?*

Would you be interested in joining a Facebook group hosted by our practice? The purpose of the group is to share health and wellness information and provide you with an opportunity to ask general questions about healthy lifestyle and nutrition.*

How did you hear about us?*

Please describe*

What are your top three health and wellness questions you would like us to address in our future content?*

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