Consideration for one-time 60-minute initial consultation questionnaire
Thank for your interest in Inspired Wellness, PLLC!  There are several important questions that I request you answer before scheduling your consultation. My Lifestyle & 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.

If it is determined that our services can help your current healthy journey, you will be emailed with a link to schedule your initial consultation (fee required to schedule appointment)***. After you have scheduled your appointment, you will receive additional emails to establish an account with the medical record system that I use.  It is called Charm.  Once you have established an account, the system will alert you to complete an in-depth questionnaire in Charm.  Providing answers ahead of time will allow me to maximize our one-on-one time together.

Thank you so much for taking the time to complete this questionnaire!

Have a wonderful day!
--Dr. Carina

***Payment for the initial consultation is required prior to your appointment as Dr. Hopen will study your case based on your questionnaire answers prior to your visit.
Sign in to Google to save your progress. Learn more
Email *
First and Last Name *
Age *
Phone Number *
What is your zip code? *
Dr. Hopen is a licensed physician in the state of Washington.  She is only able to render care to individuals who are physically in the state of Washington.  Are you physically in the state of Washington? *
What top 2 medical struggles are you seeking help for? (Please be as specific as possible). *
If your symptoms disappeared, what would you be free to do differently now? (Please be as specific as possible). *
What have you tried that has WORKED WELL for you so far? *
What have you tried that HAS NOT helped? *
If you have been to a functional specialist in the past, what did your management plan include (e.g. testing, nutraceuticals, nutrition plan, etc.)?
What do you think your BIGGEST OBSTACLE(S) might be to achieving these goals? *
Why do you feel a comprehensive, holistic medical approach may be right for you, and WHY IS NOW the right time? *
Lifestyle & 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? *
Did you know you can learn all about the details of membership (pricing, terms and conditions, testing and supplements, etc.) ahead of time? (choose one) *
Free VIP Guided Tour Link
https://inspiredwellnessacademy.teachable.com/p/vip-guided-tour
How did you hear about my services?  If applicable, please list the referral name. *
Please list the referral (clinic/specialist, or first & last name of individual) below (if applicable)
If you have not reviewed our plans and packages, go to: https://www.inspiredwellnesspllc.org/plans-pricing

In addition to a one-time 60-minute consultation, we offer two types of membership plans as well as 3x4 Genetic testing plan.
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Inspired Wellness, PLLC. Report Abuse
Google Forms