LQE FORM

How to End Severe, Long-Term or Frustrating Health Problems

Dr. Billiot is a best-selling author and the founder of Alternative Health Atlanta, one of the top holistic health care clinics in the nation. She is the developer of the EvecticsSM health improvement system, and is known nationwide as an expert and sought-after teacher of nutritional and energetic health techniques.

You can get Dr. Billiot's expert opinion on your health problems.

You will find out what may be happining with your health and why.
You'll get guidance on what to do first to start the process of recovering.

INSTRUCTIONS:

Fill out this form and tell Dr. Billiot about your health problems.
Our Reception will set up your phone consultation with the doctor.
Dr. Billiot will give you her insight on your problems and set you on the right path to recover your health.

This is a free service. (If you would like a more extensive consultation, let us know and we can arrange this).

Date/Time Submitted *

Your Name *

Your Age *

Your Email *

WE NEVER ABUSE OR SELL CONTACT INFORMATION. THAT'S A PROMISE!

Your Zip Code *

Your Phone Number *

Please enter a valid phone number.

1. Do you have a health issue that you'd like to improve or get rid of? (You can list as many as you like)

IF YES, PLEASE TELL ME ABOUT YOUR PROBLEM

2. (If you had a problem(s) in #1) How is this problem impacting or affecting your life?

DOES YOUR PROBLEM STOP OR REDUCE ACTIVITIES YOU WOULD OTHERWISE BE ABLE TO DO?

3. How long have you had this problem?

EXAMPLE: MONTHS, YEARS, SINCE CHILDHOOD, ETC.

4. What have you tried to improve or fix this problem?

EXAMPLE: DRUGS/SURGERIES, DIET, EXERCISE, SUPPLEMENTS, ETC.

5. Is there anything that makes this problem better?

EXAMPLE: MORE SLEEP, LESS STRESS, BETTER DIET, DRUGS, SUPPLEMENTS, ETC.

6. Is there anything that makes this problem worse?

EXAMPLE: POOR SLEEP, BAD DIET, STRESS, ETC.

7. QUICK HEALTH SURVEY

You can go back and add information from this survey to your previous answers if this survey reminds you of problems you had forgotten.

Your energy level?