Age Vibrantly Questionnaire for 45 minute call
*Please fill out this form so we can cover as much as possible during our chat so we can see if and how I can help you.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your birthdate?
Check off ALL apply that lead you to book a meeting:
Referral from a Wynne At Health client
Referral from a doctor
Chat on FB
Watched an online class
Saw a video
Instagram
Other
If you were specifically REFERRED, who referred you?
Which specific conditions or diseases have you been diagnosed with, if any?
What are your top 3 most frustrating symptoms right now?
How long have they been going on?
What have you tried before that has or has not worked?
What is motivating you to fix this now?
My #1 health goal in the next 30-90 days is. . .
The biggest hurdle(s) holding me back from reaching that goal is/are. . .
Who would support your efforts?
When it comes to investing in my health. . .
I make myself a priority
I sometimes make myself a priority but know I should do more for myself
I rarely advocate for myself because I know there are so many other things that are more important
Are you taking supplements or medications? List what you take and what it's for...
I have seen the following practitioner(s) in an attempt to reach my health goals: (Check all that apply)
MD/DO/PA
Traditional Medical Specialist (Endocrinologist, Gastroenterologist, Rheumatologist)
Registered Dietitian
Functional Medicine Doctor
Naturopathic Physician
Chiropractor
Holistic Nutritionist
Herbalist
Chinese Medical Professional
Massage Therapist
On a scale from 1 to 10, with 1 being the lowest and 10 being, "pants on fire!" important, how serious are you to do what it takes to improve your health in the next 30-90 days?
COMMITMENT: Our coach commits to showing up to your appointment ready and present for you and your health. Please type YES in the box below to let us know you too are committed, ready and present to honor your health.
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