On a scale of 1–10, how would you rate your physical energy level right now?
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(1 = lowest, 10 = highest)
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On a scale of 1-10 rate your mental clarity, ability to focus & create?
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On a scale of 1-10 how would you rate your emotional wellbeing?
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Tell us about your mental & emotional symptoms & how they affect your life?
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What are your top 2–3 health concerns you want help with?
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Tell me about your current symptoms and how they affect your daily life.
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If nothing changes in the next 6–12 months, how will that impact your life — personally and professionally?
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What would your life look like 6 months from now if you had the energy, clarity, and health you want?
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What have you already tried to address these issues?
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What’s been the biggest obstacle to reaching your goals?
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What are you looking for in a health partner or program?
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On a scale of 1–10, how ready are you to invest the time, energy, and financial resources to achieve lasting results?
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(1 = not ready, 10 = fully committed)
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What would make you a great fit for us to work together?
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How did you hear about Dr. Rajka?
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To ensure we spend time and attention with all of our patients, we are only able to accept new patients who are ready to transform their health. Are you ready?
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Yes
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Full Name
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Email
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Phone
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Date of Birth
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Gender
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Male
Female
Unspecified
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What is your zip code?
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