Application for Health Assessment Consult

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I'm thrilled to help you see what's possible with your health! This application is for a 15-minute Zoom Health Assessment Consultation with me, Dr. Jerry Duggar. It's the beginning of the enrollment process for my private membership practice.

During our 15-minute Zoom Health Assessment Consultation, I'll ask specific questions about your symptoms to see if functional medicine is helpful for your case. If we are a good fit to work together, you'll be invited to make an initial appointment. If we aren't a good fit, you'll walk away with a personalized email directly from me that helps steer you in the right direction with additional articles, videos and resources to consider! Win/win!

My functional medicine private practice is very unique and innovative. It's less of a "doctor's visit" and more of a "guided partnership" to sequence your steps to better health. Therefore, I only invite those action-takers that are ready to utilize health coaching, group sessions, private appointments, online classes and videos to help themselves uncover better energy, deeper sleep and improved vitality.

Have a wonderful day!

- Dr. Jerry

Email *

Please state your FIRST and LAST name *

Phone Number *

If you are not a resident of Utah, we cannot establish a Doctor/Patient relationship with you. We can, however, engage in a health coach/client relationship and this will be discussed during our appointment.

I am a resident of Utah *

What top 3 health struggles are you seeking help for? *

If those symptoms disappeared, what would you be free to do differently now? *

What have you tried that has WORKED WELL for you so far? *

What have you already tried that HASN'T helped? *

Why do you feel a comprehensive, holistic medical approach may be right for you, and WHY IS NOW the right time? *

What part of our Membership program appeals to you? (What inspired you to set up this call?) *

Functional Medicine treatment plans require consistent participation. (For example: learning about your body and building new habits around eating, movement, sleep, thinking, etc) HOW MOTIVATED are you to WORK HARD on yourself to feel better? (choose one) *

I am VERY MOTIVATED to work on my habits and lifestyle

I am INTERESTED IN STARTING some changes

I am UNSURE how much energy I can dedicate to working on myself

I am NOT READY to participate in changing my routine

Please select all that you are willing and capable of doing to improve your health

Significantly change my diet

Take recommended nutritional supplements/herbs etc.

Perform recommended lab tests

Modify my lifestyle (sleep, exercise, stress management etc.)

Be accountable to a coach and support team

Other:

During this Health Assessment Consult, I prefer to spend our time learning about you and your goals. What's ONE QUESTION that you want to make sure is discussed during your Zoom Consult? (Is there anything specific you are seeking?) *

In order to provide as much value as possible to our clients, our membership leverages many online tools. Our clients must be comfortable using computers. Please check all that apply for you: (check all that apply) *

I check email regularly

I use social media

I have enrolled in an online course before

I have been in a Zoom meeting

I do not use computers often and I prefer not to

Required

How did you hear about my services? (choose one) *

Referral from friend/family

Website/Google search

Facebook

Referral from medical provider

Other

Please list the referral name below (if applicable):

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