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Application to work with Dr. Brenda McCool
Pre Screening Form. Please complete the prospective patient form to the best of your ability!
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Dr. McCool's office is a scent free environment. Please refrain from using perfumes and colognes. Thank you for your cooperation.
Dr. McCool honors medical sovereignty and welcomes unvaccinated individuals into her practice.
Email
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Name (first and last)
*
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Full address including city, state and zip code *
We must have this in order to schedule your appointment
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Best contact phone number *
Your answer
Date of Birth
Your answer
How did you find Dr. Brenda McCool?
Your answer
What are you looking for help with?
Digestion: Reflux, Gas, Constipation
Sleep: Falling asleep or staying asleep
Sense of well being
Energy
Other:
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Briefly list your health concerns in order of priority (ie fatigue, gas, bloating, hot flashes)
Your answer
What have you tried doing to resolve this problem that
Did Not
work?
Your answer
Have you become discouraged or stressed about handling this problem?
Your answer
When your problem is at its worse how does it make you feel?
Your answer
Do you know how this problem may have started?
Your answer
Do you have any medical conditions that Dr. McCool should be aware of? If so, what are they? please list them:
Your answer
Are you taking any pharmaceutical medications? Prescribed medications only (not supplements) please list them
Your answer
How long have you been experiencing symptoms?
< 6 months
6-12 months
1-3 years
3+ years
Have you ever worked with another practitioner for this issue? If yes, please explain more
Your answer
Describe what your optimal health looks like 6 months from now (please be specific ie I have no more gas or bloating, my energy is a 10/10, I have lost 10 pounds
Your answer
What potential barriers do you forsee that would prevent these things from happening?
Your answer
Do you feel it is possible to eliminate or prevent these potential barriers?
Your answer
What are your strenghts that will enable you to accomplish your goals?
Your answer
Please rate your overall health (1= I am often sick and have a lot of health concerns, 5 = I'm feeling the best I've ever felt
1
2
3
4
5
What do you want most from Dr. McCool? (general health advice, someone to hold me accountable in undertaking my lifestyle changes, someone to manage labs and medications)
Your answer
Do you currently follow an exercise routine? If no, are you willing to begin one that is tailored to you and your current abilities?
Your answer
Your health is an investment that could potentially save you thousands in future medical bills. How much are you willing to invest in your health per month?
<500
500-1,500
I'm priceless
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On a scale of 1-10 (1 = I don't want to change anything, 10 = I am willing to change anything and everything if needed) how committed are you to improving your health right now?
Your answer
On a scale of 1-10 (1= I have no interest in a health coach, 10= I would love having someone coach & guide me) do you feel that you are coachable and would enjoy a mentor helping you?
Your answer
On a scale of 1-10 how important is it for you to resolve your health concerns? (1 = I can live in my current state of health indefinitely with no problem, 10= I have got to change the course of my health NOW!)
Your answer
Is there anyone else involved in your health and financial decision-making process?
Nope just me!
Yes, I have another family member I need to consult with before making this decision
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