FREE 20 Minute Consultation Questionnaire

It’s great to see you here! I’m keen to get in touch with you to arrange your FREE consultation.

Please take the time to fill in the following questionnaire, as it will help me to tailor your consult to your needs, ensuring our time is effective.

Name *

First

Last

E-mail *

Age

How did you hear about us?

Are you on any prescription medications?

If yes, what are the medications you are taking?

Are you open to proven natural therapies?

On a scale of 1-10, how would you describe your HEALTH?

1 = Extremely Unhealthy ------- 10 = Extremely Healthy

On a scale of 1-10, how would you rate your ENERGY and MENTAL CLARITY of a day?

1 = Extremely Low ------- 10 = Extremely High

On a scale of 1-10, how would you rate your EATING HABITS?

1 = Extremely Poor ------- 10 = Extremely Good

On a scale of 1-10, how well do you SLEEP?

1 = Extremely Poor ------- 10 = Extremely Well

On a scale of 1-10, how well do you get EXERCISE and SUNSHINE into your day?

1 = Extremely Poor ------- 10 = Extremely Well

On a scale of 1-10, how much TIME and FINANCIAL FREEDOM do you have right now?

1 = Extremely Low ------- 10 = Extremely High

On a scale of 1-10, how would you rate your JOB SATISFACTION?

1 = Extremely Unsatisfied ------- 10 = Extremely Satisfied

Is there anything else you think I should know?

Phone Number

Skype Address

Name

This FREE consultation is limited to one consultation per person.