First Name *

Last Name *

Email *

Phone *

Date of birth *

Gender *

Male

Female

Can you please describe your current health concerns and symptoms in detail? *

How long have you been experiencing these symptoms? *

Are you currently taking any medications, supplements, or over-the-counter drugs? If so, please list them. *

Do you follow any specific diet or exercise regimen? *

Have you tried any treatments or interventions for your current health problems? If so, what were the results? *

Have you noticed any factors that seem to trigger or worsen your symptoms?

What, specifically, are you wanting to achieve? (Ex: Lose weight, have more energy, etc…) *

What do you think is stopping you from achieving your goals and improving your health? *

On a scale of 1 - 10 how committed are you to doing whatever it takes to solve this problem? (1 being not committed, 10 being 100% committed.) *

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Why is this call important for you? Having a major reason "why" is imperative to improving your health! (Ex: I need to lose 30 lbs. and improve my energy so that I can be here and enjoy my grandkids.) *

How much are your health issues/symptoms impacting your life? (1 being not a major concern, and 10 significantly impacting your life?) *

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Are you frequently tired, even after a full night's sleep? *

Do you find it challenging to complete daily tasks due to exhaustion? *

Have you noticed a significant decrease in your energy levels over time? *

Have you had chronic fatigue for six months or longer without improvement? *

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