Science of Human Optimization

Science of Human Optimization

Confidential Assessment Form
Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
1. What is your main health complaint?
2. Was there a stressful life event that you believe contributed to the condition?

Yes No
3. How has this condition affected your lifestyle?
4. What are the top three foods you eat daily and / or crave?
5. What medication / supplements are you taking for your condition now?
6. Have you gained (or lost) weight inexplicably and have trouble loosing weight no matter how you eat or exercise?
7. Do you believe there is a permanent resolution to the underlying cause?

Yes No
8. Would you be willing to adjust your diet, take the recommended supplements, adhere to a detoxification program, or an intravenous therapy schedule, as part of the treatment plan?
9. Do you currently have amalgam (mercury) fillings?

Yes No
10. Have you ever had a root canal, implant or major dental work done?

Yes No
11. Would you be willing to go through an educational program to understand the lifestyle and nutritional protocols for faster recovery?
12. On a scale of 1-10 how committed are you to the permanent resolution of the chronic condition?
Is there anything else you would like us to know that may offer insight in helping you achieve your health goals?
AGREEMENT

We are NOT looking to diagnose or treat any particular disease, or condition.

Our focus is to identify deficiencies, toxicity, and/or a compromised system of digestion that may be interfering with peak-performance function.

We are waving the cost for the initial consultation ($200 value) and the next steps will be explored, when we come to trust that we can produce results worthy of the effort.
Should be Empty: