First Name
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Last Name
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Email
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Phone
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Please tell us your sex:
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Female
Male
Are you located in Southern California?
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Yes
No
Are you willing to travel to Buena Park for in-person visits with Dr. Augustine?
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Yes
No
To ensure you receive the precise treatments you need without insurance restrictions, we operate on a cash-pay system. Does this work for you?
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Yes
No
What is your monthly budget for out-of-pocket expenses?
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Under $300 per month
$500 - $1,000 per month
$1,000 - $2,500 per month
Over $2,500 per month
Do you have any specific health concerns or symptoms you would like to address?
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Autoimmune Issues
Cancer
Hormonal Health (PCOS, Menopause, etc.)
Gut Health Issues
Sleep Issues
Thyroid Issues
Diabetes
Chronic Fatigue
Heavy Metal Exposure
None of the Above
What is your primary goal for your health?
Resolve my immediate symptoms
Achieve long-term wellness through a customized program
Find the root cause of my chronic illness
Get my body to start healing from my chronic illness
All of the above
Are you currently on any medications?
Yes
No
Please check all the treatments you have tried for your condition(s) that have helped:
Prescription Medications
Surgery
Chiropractic
Acupuncture
Alternative/Holistic Medicine
Exercise
Dietary Changes
Supplements
How would you rate your current stress level?
Low
Moderate
High
Very High
How often do you engage in physical activity?
Never or Very rarely
Occasionally
Regularly
Daily
Which of the following best describes your current diet?
Standard American Diet
Mediterranean Diet
Vegetarian/Vegan Diet
Paleo Diet
Carnivore
Unhealthy
I am not sure
How would you describe your current mindset regarding conventional medicine?
Conventional medicine has failed me. My health hasn't improved.
I believe in conventional medicine, but I know they don't have all the answers.
Conventional medicine is great for things like emergencies, but I want to get better naturally, i.e., without medications).
Conventional and functional medicine practices work well together.
How did you hear about us?
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