Functional Wellness Form | CultureandHealthCo

First name

Last name

Phone

Please share your current health concerns/struggles, in order of importance.

What is your ultimate long-term goal?

What are you currently doing for your health, nutrition, and fitness?

Have you tried anything in the past (or recently) to change your habits, your health, your eating, and/or your body? If so, what?

Do you currently take any medications or supplements? If so, please list or link them below - the brand, dosage, etc.

Have you worked with a Functional Wellness Practitioner before?

Yes

On a scale of 1-10 (10 being the most ready), how ready are you to commit to your goal(s)?

If you answered less than 9 (<9), why didn't you answer higher?

I fully believe that if everything is not a "heck yes," it's a no. Let us know how you are feeling right now. :)

Heck yes, I'm ready!

I'm ready, but scared.

Preferred way of contact?

Text

Phone call

For legal purposes, I must include this statement and get your consent by typing your First and Last Name below: I understand this is educational, not medical advice. I will speak with my healthcare provider when in need.

Additional comments (optional)