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PLEASE FILL OUT THIS 60 SECOND SURVEY

From the list below, what health improvements are most important to you? (Select All That Apply) *

Reduce Medication

Lower Blood Pressure

Improve Heart Function

Lose Weight

Lower Stress and Anxiety

Improve Sleep

How long have you had your symptoms? *

2 months or less

3 months - 12 months

1 - 2 years

3 years +

As long as I can remember

Which of the following have you tried to fix your health issues? *

Seeing my doctor

Medications

Natural supplements

Therapy

Functional medicine

Lifestyle improvements

How healthy would you say your lifestyle is? *

Bad - I have no regard for my lifestyle choice

Okay

Average

Good

Great - I consistently prioritize my health, diet and exercise.

How would you rate your stress level? *

0

1

2

3

4

5

What is your biggest source of stress? *

Finances

Family

Work

My Health

Holistic & functional medicine is not covered by insurance. Would you have at least $1000 available to invest in your health? *

Yes, if I felt confident

Not at this time

Full Name *

Phone *

Email *

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