HEALTH READINESS ASSESSMENT
The following questionnaire will give our team more information to determine if you are a good fit for our new programs.
Full Name
*
First Name
Last Name
Gender
*
Male
Female
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Are you able to attend dinner with Dr. Brown at Luca restaurant (formally Passion8) on the following dates?
*
April 4th @ 6:00pm
April 6th @ 6:00pm
Not available but would like to attend a future presentation.
Are you currently a Carolina HealthSpan Institute Patient?
*
Yes
No
I have been a patient in the past but am not currently active
I am the spouse, partner or guest of a current patient
Would you like improvement with any of the following?
*
Weight loss
Energy Level
Disease Prevention
Libido
Digestive Support
Cardiovascular Protection
Stress Management
Memory / Concentration
Sense of Well Being / Anxiety
Other
What are your top three health concerns?
*
What have you tried to resolve these problem that DID NOT work?
*
What are you afraid this is currently affecting or will be affecting without change?
*
Job
Kids
Marriage
Sleep
Freedom / Independence
Finances
Future abilities
Time
Are there any specific health conditions you are concerned with for your future?
*
Stress
Diminished physical abilities
Weight gain
Heart disease
Depression
Neurodegeneration (i.e. Dementia)
Surgery
Arthritis
Osteoporosis
Cancer
Diabetes
Attention Deficit Disorder (ADD/ADHD)
Other
Rate the following four questions: 1 - 10 (1=poor / 10=excellent)
How do you rate your current level of health
*
How important is it for you to resolve your health concerns?
*
Do you feel that you are coachable and would enjoy a mentor in helping you achieve your goals?
*
How prepared are you to make the appropriate lifestyle changes that may be necessary in order to achieve your goals?
*
Finish
Should be Empty: