Client intake form Name * First Name Last Name Email * Phone * (###) ### #### Date of birth MM DD YYYY Which time zone are you in? * How did you hear about us? Friend Instagram Google Search Other What are your main health complaints? Tell me all the things! * When did these symptoms begin? * Did something trigger a change in your health? * Are you trying to conceive? * Yes No Eventually Who or what do you think are the biggest obstacles in reaching your current health goals? * Why is it important that you solve these health issues right now? * How often does it bother you? * How long has it been going on for? * What have you tried so far that has not worked? * How does this affect your life or what does it prevent you from doing? * Who or what (fear, money, time) may stop you from completing a health rebuilding program (who will support you)? * What would you (reasonably) expect to achieve while working with me? * On a scale of 1-10 how important is it to solve this? * Thank you! One of our members from our team will be reaching out to you!
