Pedre Integrative Health - Patient Application Form

You can always press Enter⏎ to continue

Now create your own Jotform - It's free!Create your own Jotform

Patient Application

Patient Application

Hi there, thank you for taking the initiative and saying "Yes!" to yourself! You are applying to work with Dr. Pedre in an intensive healing program. By applying to become an active participant in your health goals, you are taking back your power as a patient. (Please answer the following questions as honestly as possible to determine if we are a good fit for each other.)

21Questions

1
What is your name? (First, Last)
2
Where do you live? (City, State, Country if outside the U.S.)
3
What’s your cell phone number?
(XXX-XXX-XXXX)
4
What’s your primary email address?
5
What's your preferred method of communication?
Cell
Email
Text message
Any of the above
6
What is the main health concern you want to work on?
7
What have you tried so far to resolve your main health concern?
8
Why do you think it hasn't worked?(What has been successful? What has NOT been successful?)
9
On a scale of 1-10, how would you rate your physical health? (1 = lowest; and 10 = highest)
10
On a scale of 1-10, how would you rate your mental clarity and ability to focus and get things done during the day? (1 = lowest; and 10 = highest)
11
On a scale of 1-10, how would you rate your emotional well-being? (1 = lowest; and 10 = highest)
12
Tell us about your physical symptoms and how they affect your life.
13
Tell us about your mental and emotional symptoms and how they affect your life.
14
What would you be able to accomplish if you were feeling at your best?
15
What’s getting in the way of you reaching your health goals?(Be as specific and honest as possible.)
16
What do you hope to accomplish by working with Dr. Pedre?
17
How much time (including mindfulness, meditation, exercise, shopping for food, food prep, and appointments) are you willing to put in weekly to achieve your health goals?Only choose one.
1 - 2 hours per week
3 - 5 hours per week
6 - 8 hours per week
9 - 11 hours per week
As much time as it takes
18
Select the one that describes you the best.Only choose one.
a. I have the financial resources to invest in my health and want to work 1:1 with Dr. Pedre. (Complete access, including text messaging and email)
b. I have the financial resources to invest in my health, but I'm more self-directed and don't need complete access to Dr. Pedre. (Limited access)
c. I have the financial resources to invest in my health, but prefer to keep it within a certain budget and focus on foundational issues, like my gut health.
d. I really want to invest in my health, but I have limited resources.
19
What would having your best health be worth to you?Only choose one.
Less than $2,000 per month
$2,000 - $5,000 per month
$5,000 - $10,000 per month
> $10,000 per month
20
Who referred you to Dr. Pedre’s Program? (Or how did you hear about us?)
21
How soon are you ready to begin?Only choose one.
Within 1 - 2 weeks
In 2 - 4 weeks
4 - 6 weeks
6 - 8 weeks
Not urgent, just looking into my options
Should be Empty:

Pedre Integrative Health - Patient Application Form

[Edit]

Question Label

1 of 21See AllGo Back

Save & Continue Later

Your form is saved successfully!

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Please enter a valid email address.

Something went wrong while saving your answers. Please try again.

Email has been sent successfully.

Save your progress

OR

Already have an account? LOGIN

Skip Create an Account

Save your progress

Name

Email Address

Password

I agree to theTerms of ServiceandPrivacy Policy

Your form submission has been saved as a draft.

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Save your progress

OR

Username or email

Password

Forgot Password?

Your form submission has been saved as a draft.

We’ve sent you an email with a link to complete your submission.