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Dr. Terra Winston's Prospective Patient Application
Pre Screening Form
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Email
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Your email
EARTH NATUROPATHIC IS A SCENT FREE FACILITY. PLEASE REFRAIN FROM USING PERFUMES AND COLOGNES. THANK YOU FOR YOUR COOPERATION.
Name (First and Last)
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Your answer
Full address including City, State and Zip
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We must have in order to schedule you an appointment.
Your answer
Best contact phone:
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Your answer
Date of Birth
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Your answer
How did you find Dr. Terra Winston?
Your answer
In what state do you currently live? (Please note: Dr. Winston is not seeing international patients at this time)
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Your answer
What are you looking for help with?
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Joint pain or injuries
Autoimmune disease
Gut health
Lyme Disease
Aesthetics
Anti-aging
Hormonal issues
Mold Illness
Weight loss
Other:
Required
Please list briefly what you're looking for help with (i.e. "irregular periods," "just diagnosed with lyme disease," "thyroid disorder," etc)
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Your answer
Do you have any medical conditions Dr. Winston should be aware of? If so, what are they?
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Your answer
Are you taking any pharmaceutical medications? (prescribed meds only, not supplements) please list them:
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Your answer
How long have you been experiencing symptoms?
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<6 months
6 - 12 months
1 - 3 years
3+ years
Required
Have you ever worked with another practitioner for this issue?
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Yes
No
Required
If yes, please explain more.
Your answer
In an ideal world, describe what your health will look like 6 months from now (try to get specific, i.e. "I will have regular periods, no more acne, and feel energetic")
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!) *
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1
2
3
4
5
What do you want most from Dr. Winston?(i.e. general health advise, someone to hold me accountable in undertaking my lifestyle change, someone to manage labs and meditations, etc.)
Your answer
Do you currently follow an exercise routine? If so, please describe. 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 will potentially save you thousands in future medical bills! How much is your health worth per month?
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<$500
$500-$1000
Im priceless
If you are currently facing financial challenges and you would like information on Dr. Winston's 501c3 non-profit clinic program, please check this box.
Yes, I would like more information on this option.
On a scale of 1-10 (1= I don't want to change anything, and 10= I am willing to change anything and everything if needed), how committed are you to improving your health right now?
1
2
3
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5
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7
8
9
10
Clear selection
Is there anyone else involved in your health and financial decision-making process?(spouse, family member, etc)
Nope! Just me.
Yes, I have another family member I need to consult with before making this decision.
Clear selection
If you could only eat one thing for the rest of your life, what would it be? (this is just for fun!)
Your answer
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