Getting To Know You Survey

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Pre-Screening Questionnaire. Please fill out this survey, and I will give you a call as soon as possible, during business hours (9am-5pm) Monday through Friday. Thank you!

What is your name? Please include first and last *

What email address may be used to contact you? *

What phone number may be used to contact you? *

When is the best time to contact you? *

Morning

Afternoon

After hours (5pm-7pm)

Required

I currently provide functional health coaching to patients in Florida at this time. Are you a resident of FL? *

Yes

Are you filling out this survey for yourself or another person? *

Yes

Select all that apply. *

Looking for support with specific health conditions, such as irritable bowel syndrome, type 2 diabetes, hypothyroidism, and autoimmune disease.

Lose weight, increase energy, or I'm not feeling as good as I could be

I have been chronically ill for a long time and no one has been able to help me feel better

I was referred to you by another practitioner. (Please let us know in the space below).

Other

Required

What have you tried so far to address your goal? (diet, tests, etc.) *

Not much, just getting started.

I have tried a few things, but I am overwhelmed by the information out there.

I have been to multiple practitioners trying to figure this out and but it's still a mystery.

Other:

Required

Which of the following items are currently in your diet in any amount (select all that apply) *

Soda

Diet soda

refined sugar

alcohol

fast food

snack foods (pretzels, chips, etc.)

dessert, candy, chocolate chips (sweets)

dairy (milk, cheese, yogurt)

coffee

Required

What percentage of your meals are currently home cooked? *

less than 25%

25-50%

50-70%

70-100%

Referral Name:

Any comments, questions, concerns you would like to add?

Submit

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