Health Consultant Services: Questionnaire (H.E.A.R.O. INC)
The purpose of this questionnaire is to determine what Health Services are need in order for you to reach your realistic health outcome, one step at a time.  This form will allow us to help you overcome your obstacles as you work to achieve your overall physical, mental, financial, emotional, and social health.  Upon completing this form, a member of our team will reach out to schedule a one:one consultation with you or your organization.  Thank you for choosing us to help you with your working towards improving your overall well-being!  ***Disclaimer:  As a Healthcare Non-Profit Organization, our Health Educators/Consultants are not licensed Physicians, nor are we claiming to practice as your Nutritionist or Physician.  We encourage all of our participants to keep up with their regularly scheduled and annual visits with their healthcare professional. Our purpose is to provide advice and act as a consultant to assist you in meeting your health goals to help improve your overall health.  You are not required to take our suggestions in lieu of what has been suggested by your healthcare professional.  By completing ths form, and participating in our services, you agree to complete any necessary forms that will follow this questionnaire to help ensure your health and your safety.***
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電子郵件 *
General Demographics:
Please answer the general questions below:
Name: *
Contact Number: *
Date of Birth: *
MM
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Address: *
Are you under the care of a Physician? *
If you answered yes to the above question, please provide a brief explanation.  Your health is always going to be our first priority. *
Do you have any pre-existing or autoimmune disorders that could impact your overall health, or require any special diet? *
If you answered yes to the above question, please breifly describe your condition, and how HEARO can assist you on this journey to achieving a overall improvement in your health. *
Services Offered: Please select the services you would like to receive. *
必填
What are your goals to developing a overall well-being? *
How soon are you looking to get started with achieving your health goals? *
How would you like to schedule your consulation? *
Would you like to become a subscribed member with HEARO? (There's no cost to subscribe.  You may do so at www.myhearo.org)  Subscription includes notifications about all upcoming events, and discounts for services.   *
By completing this questionnaire, you are verifying that all of the information you have provided is true/accurate to the best of your knowledge. *
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