Reverse Med SRQ General Health

1
Hey! Let's start simple, which of the following best describes your current state?* This field is required.
Feeling Older
Feeling Stressed
Feeling Lethargic
Feeling Unsure
2
What past investments have you made in your health?Check all that apply:
Gym Membership/Workout Plans
1:1 Personal Trainer / Online Coaching / Nutritionist
At Home Diet Plans
TRT / HGH / Peptides / Functional Medicine/ etc
Peloton / Tonal / Fitness Technology
I have never invested in my health
3
What is your name?* This field is required.
First Name
Last Name
4
Gender (optional):
Male
Female
5
Great! What is a good email to have on file?* This field is required.
example@example.com
6
Do you currently have a primary care provider (PCP) managing your healthcare needs
Yes
No
I have in the past 6 Months
7
If yes what is their name and location?
8
Are you still interested in learning more about Dr. Rucker's Health Coaching approach?
Yes! Let's Talk!
No I'm no longer interested.
I'm not sure, need more info.
I would like to keep filling out the form.
9
What Treatments Would You Like to Ask Dr. Rucker About?Dr. Rucker can provide custom bundles that are tailored to you if needed.
Testosterone Therapy
Medical Cards (Anxiety/PTSD) Florida Residents Only
Peptides
ADHD
Erectile Dysfunction Treatment
General Care/Telemed
10
What Medications Are Your Currently On?
Huge
Large
Normal
Small
Ok
Ok
11
What is your Health Goal over the next year?Please be specific and explain why you need Dr. Rucker’s help. Goals do not need to be physical goals.
Huge
Large
Normal
Small
Ok
Ok
12
What do you feel was your Biggest Obstacle to achieving your goal AND/OR sustaining it? Please provide as much detail as you can* This field is required.Biggest obstacle in your way. Don't think too hard, just write what comes to mind
Huge
Large
Normal
Small
Ok
Ok
13
What Interests You About Our Clinic?
Huge
Large
Normal
Small
Ok
Ok
14
When is your Birthday?* This field is required.We need your date of birth due to reverse being a medical prescription.
15
We try to make working with Dr. Rucker Affordable for all Budgets (Plans start at $50 a month Plus Medication Costs). Med Cards are now just $20 Monthly. We will give you the option to pick up your medication at a local pharmacy of your choice or through us. If you like what you hear from him during your call how quickly are you ready to START?
Yesterday
Today
Not Ready Yet
Would like More Info First
16
Where are you Located?Just Zip Code or City is fine!
17
When was the last time you had bloodwork done?
Date
Year
Month
Day
18
Which Type of Plan Interests You?This helps Dr. Rucker propose the most realistic option for your Health & Wallet!
I want A Basic Treatment
I'm Interested in Options
I want THE WORKS!
19
ONE LAST STEP! Enter your phone number & Click NEXT to have a Success Coach reach out to you for a call with Me. On this call, we will see if you are a good fit and give you a full breakdown of our program. * This field is required.I will also reach out by texts to reach your needs sooner! - Dr. Rucker
Please enter a valid phone number.
Should be Empty: