Health Readiness Assessment

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 NameLast Name
Gender*

MaleFemale
E-mail*
Phone Number*

Area CodePhone Number
Are you able to attend dinner with Dr. Brown at Luca restaurant (formally Passion8) on the following dates?*

April 4th @ 6:00pmApril 6th @ 6:00pmNot available but would like to attend a future presentation.
Are you currently a Carolina HealthSpan Institute Patient?*

YesNoI have been a patient in the past but am not currently activeI am the spouse, partner or guest of a current patient
Would you like improvement with any of the following?*

Weight lossEnergy LevelDisease PreventionLibidoDigestive SupportCardiovascular ProtectionStress ManagementMemory / ConcentrationSense of Well Being / AnxietyOther
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?*

JobKidsMarriageSleepFreedom / IndependenceFinancesFuture abilitiesTime
Are there any specific health conditions you are concerned with for your future?*

StressDiminished physical abilitiesWeight gainHeart diseaseDepressionNeurodegeneration (i.e. Dementia)SurgeryArthritisOsteoporosisCancerDiabetesAttention 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?*
Should be Empty:

HEALTH READINESS ASSESSMENT