Pedre Integrative Health - Patient Application Form

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

How could we deliver 10X that value to you?Limit answer to 200 words or less.

0/200

21

Who referred you to Dr. Pedre’s Program? (Or where did you hear about us?)Ex. Instagram, Google search, Blog post

22

What attracted you to work with us?Limit answer to 200 words or less.

0/200

23

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