I look forward to helping you achieve a higher state of health!  Please complete the following readiness assessment.
*Please note that I am located in beautiful Greenville, SC and I need to see you in person for the initial appointment.
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Full Name: *

 
City, State, and Zip Code *

 
Phone: *

 
Age: *

 
Gender: *

 
Occupation: *

 
Do you smoke? *

     
 
How did you hear about my practice? If you were referred by someone, list their name here so I can thank them. *

 
What prompted you to reach out to me today? *

 
Have you ever been a patient of a functional, integrative, holistic, complementary, or alternative medicine practitioner?

     
 
Please elaborate and tell me about that experience.

 
Your health is your most valuable asset. It profoundly affects everything else in your life including your relationships, your professional and academic success, and your happiness.

The best results are achieved when you are an active and willing participant, not just trying to make someone else happy.

That's why I want to make sure you're ready.


 
List the top 3 health-related problems that affect your daily life: *

 
What things you have been unable to do as a result of your present level of health and/or symptoms? *

 
What are you looking forward to doing once you are feeling better? *

 
In order to get the result you desire, how willing are you to do the following: (5 stars being highest)

 
Significantly modify what and how you eat?






 
Perform laboratory assessments that may include collection of blood, urine, stool, hair and saliva?






 
Take nutritional supplements each day?






 
Keep a detailed record of everything you eat for several days?






 
Modify your lifestyle (e.g. work demands, sleep habits, environment)?






 
Practice relaxation techniques daily?






 
Exercise at least 2 days a week, or reduce your amount of exercise if necessary?






 
Communicate with me frequently in order to achieve your goals?






 
Have periodic lab tests to assess your progress?






 
At the present time, how supportive do you think the people in your life will be to your implementing the above changes?






 
In the spirit of honesty and respect, I need to tell you that functional medicine can be time-consuming and expensive.  Are you prepared to invest time and money in your health?

 
More information is better! Please include any other comments here:

Thank you for taking the time to share this information with me. Please make sure you have reviewed the practice information and rates on my website, then book a complimentary 15-minute consultation call so we can get to know each other better:

Book my call
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Thank you for your interest, but if you're still smoking you're not ready to be a functional medicine patient. I encourage you to start a smoking cessation program ASAP. Once you've conquered that hurdle, the sky is the limit!
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This type of health care requires a significant amount of time and money.  Not everyone is ready or able to make the investment in themselves and claim a life of vitality and well-being.  When you are, you know where to find me!
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