Active Wellness Program Discovery Call Application

Application For A 20-Minute Discovery Consultation

Please answer the questions as thoroughly as possible. We select applicants based on who we feel will best match our program, and we want to make sure we can meet your needs. We look forward to getting to know you and helping you on your healing journey

Patient Information

First Name *

Last Name *

Middle Initial: *

Address *

City *

State *

Zip *

Home Phone:

Work Phone (and ext):

Cellphone:

Email *

What is your preferred method of contact?

Text
Phone Call
Email

Birthdate: *

Gender *

Male
Female

Height *

Weight *

Employer *

Occupation *

Marital Status:

Single
Married
Separated
Divorced
Widowed

How did you find our clinic? *

Symptoms and Complaints

Please list your top 3 - 6 symptoms in order of importance. Include how frequently you experience each symptom and how severe it is (severity 1=mild, 10=severe). Please note things like “SIBO” or “Adrenal fatigue” or “hypothyroid” or “inflammation” are not symptoms. Bloating, gas, fatigue, insomnia and joint pain are symptoms.

Symptom

Severity 1 - 10

Frequency: Constant, Intermittently or Occasionally

Symptom 1

Severity of Symptom 1

Frequency of Symptom 1

Symptom 2

Severity of Symptom 2

Frequency of Symptom 2

Symptom 3

Severity of Symptom 3

Frequency of Symptom 3

Symptom 4

Severity of Symptom 4

Frequency of Symptom 4

Symptom 5

Severity of Symptom 5

Frequency of Symptom 5

Symptom 6

Severity of Symptom 6

Frequency of Symptom 6

How would you describe the complexity of your condition?

1. Mild complexity (little impact on quality of life)
2. Moderate complexity (affects most aspects of my life)
3. Severe complexity (I have been to numerous doctors and I am still suffering without answers as to why I feel the way I do)
4. I need help immediately (If you are thinking that you are this option, we are not the right place for you at this time)

Please list current medications:

Please list current herbal and nutritional supplements:

Please list any allergies to medication/supplements/food and reaction to them:

Describe the nature of your job/work:

Do you have a supportive spouse, significant other, or friend to support your health goals?

How familiar are you with functional medicine?

Not at all
Somewhat
Familiar
Very familiar

Have you worked with?

Doctor of Oriental Medicine
Functional Medicine Practitioner
Naturopathic Doctor
Clinical Nutritionist
Functional Health Coach
Other

Have you been diagnosed with an autoimmune disease?

What, specifically, are you wanting to achieve?

What’s your #1 challenge when it comes to your condition?

What else have you tried or invested in to help to solve your condition?

What do you think is stopping you from improving your condition?

On a scale of 1-10 how committed are you to doing whatever it takes to solve this problem? (Make dietary modifications, lifestyle changes, perform lab testing, take customized supplements and be coachable)

Why is having this consultation a MUST for now?

Why is solving this problem a MUST for you now?

Why not just keep doing what you’re currently doing to solve this?

How much are your health issues/symptoms impacting your life?

Is this important enough that you’re ready & willing to allocate funds & invest in yourself?

What specific improvements in your health would you consider a successful outcome in your case?

If you are determined to reach your optimal health and are willing to commit the time, effort, and investment in your health $3,000-$5,000 over the next 4-12 months to achieve it?

Yes, I am ready to get started
No, it’s not the right time
I am on the fence

In order to qualify for your 20-minute complimentary consultation we ask you to bring your significant other along with you because you are making an important decision and investment in your future health.

Yes
No
Not Sure

Have you read the Consumer’s Guide to Choosing a Functional Medicine Practice? (copy)

Yes, I have
No

Have you watched the video Why Integrative Optimal Wellness is So Effective?

Yes, I have
No

Do you agree you are not currently undergoing treatment for cancer

Yes, I agree.

Do you have any questions that you want to be sure we address when we speak?

Comment

Patient Information

First Name *

Last Name *

Middle Initial: *

Address *

City *

State *

Zip *

Home Phone:

Work Phone (and ext):

Cellphone:

Email *

What is your preferred method of contact?

Text
Phone Call
Email

Birthdate: *

Gender *

Male
Female

Height *

Weight *

Employer *

Occupation *

Marital Status:

Single
Married
Separated
Divorced
Widowed

How did you find our clinic? *

Symptoms and Complaints

Symptom

Symptom 1

Symptom 2

Symptom 3

Symptom 4

Symptom 5

Symptom 6

Severity 1 - 10

Severity of Symptom 1

Severity of Symptom 2

Severity of Symptom 3

Severity of Symptom 4

Severity of Symptom 5

Severity of Symptom 6

Frequency: Constant, Intermittently or Occasionally

Frequency of Symptom 1

Frequency of Symptom 2

Frequency of Symptom 3

Frequency of Symptom 4

Frequency of Symptom 5

Frequency of Symptom 6

How would you describe the complexity of your condition?

1. Mild complexity (little impact on quality of life)
2. Moderate complexity (affects most aspects of my life)
3. Severe complexity (I have been to numerous doctors and I am still suffering without answers as to why I feel the way I do)
4. I need help immediately (If you are thinking that you are this option, we are not the right place for you at this time)

Please list current medications:

Please list current herbal and nutritional supplements:

Please list any allergies to medication/supplements/food and reaction to them:

Describe the nature of your job/work:

Do you have a supportive spouse, significant other, or friend to support your health goals?

How familiar are you with functional medicine?

Not at all
Somewhat
Familiar
Very familiar

Have you worked with?

Doctor of Oriental Medicine
Functional Medicine Practitioner
Naturopathic Doctor
Clinical Nutritionist
Functional Health Coach
Other

Have you been diagnosed with an autoimmune disease?

What, specifically, are you wanting to achieve?

What’s your #1 challenge when it comes to your condition?

What else have you tried or invested in to help to solve your condition?

What do you think is stopping you from improving your condition?

Why is having this consultation a MUST for now?

Why is solving this problem a MUST for you now?

Why not just keep doing what you’re currently doing to solve this?

How much are your health issues/symptoms impacting your life?

Is this important enough that you’re ready & willing to allocate funds & invest in yourself?

What specific improvements in your health would you consider a successful outcome in your case?

If we can find a natural solution to permanently address your health issues, are you capable of investing $4000 - $8000 over the next 6-12 months?

Yes, I am ready to get started
No, it’s not the right time
I am on the fence

Do you agree you are not currently undergoing treatment for cancer

Yes, I agree.

Do you have any questions that you want to be sure we address when we speak?

Comment

What You Can Expect From Your Discovery Call:

Benefit #1:Tell Your Story and Be Heard

The discovery call is a time for you to tell your story and be heard. We want to get to know you, understand your journey, and learn how we can help.

Benefit #2: Find Out If Activate Wellness Program Is Right For You

Find out if Activate Wellness Program is right for you, and get your questions about the process answered.

Benefit #3: Learn The Next Steps to Feel Your Best

If we are a good fit to work together, we will walk you through the next steps to enroll in the Activate Wellness Program. If not, this call is our gift to you.

Application For A 20-Minute Discovery Consultation

Patient Information

Symptoms and Complaints

Symptom

Severity 1 - 10

Frequency: Constant, Intermittently or Occasionally

Patient Information

Symptoms and Complaints

Symptom

Severity 1 - 10

Frequency: Constant, Intermittently or Occasionally

What You Can Expect From Your Discovery Call:

Restore Your Health,

And Get Back to Enjoying Your Life