top of page
Body Well Balanced
HOME
SERVICES
ABOUT
FAQ
FAVORITE PRODUCTS
More
Use tab to navigate through the menu items.
Online Functional Health Practice with a Holistic Approach
BWB Program Assessment Form
First name
*
Last name
*
Email
*
Phone
*
Address
*
Birthday
*
Month
Month
Day
Year
Date
*
Month
Month
Day
Year
What is your main health complaint?
*
How often does it bother you?
*
How long has it been going on?
*
Have you worked with other functional health practitioners?
*
How does it affect your life? What does it prevent you from doing?
*
What have you tried that has not worked?
*
What is your profession or employment?
Who or what (fear, money, time) may stop you from completing the health program (who will support you)?
*
What would you (reasonably) expect to achieve while working with me?
*
List any current diagnosis
*
Have you been diagnosed with cancer, or have been diagnosed in the past?
On a scale of 1-10, how committed are you to solving your main health complaint?
*
On a scale of 1-10, how willing would you be to remove sugar from your diet for the duration of the program?
*
On a scale of 1-10, how willing would you be to remove gluten from your diet?
*
On a scale of 1-10, how willing would you be to remove alcohol from your diet for the duration of the program?
*
The success of this program relies on your level of commitment, how willing are you to make necessary changes to your diet and lifestyle?
*
In a brief paragraph, explain why you think the BWB Program would be a good fit for you.
*
Which labs do you wish to add for Phase 1
Blood Sugar Balancing
Food Sensitivity
HTMA
Not Sure
Submit
Thank you!
Expect to receive a response in the next 2 weeks
bottom of page
