Full Name

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On a scale of 1-10 (1 being "not at all", 5 being "somewhat" and 10 being "I'm 100% ready!"), how ready are you to commit and make the necessary changes to achieve your goals?

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10
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How did you hear about us?

Referred by Friend
Referred by Doctor
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If referred to Complete Health at Green Oaks, by who?

What are the specific health challenges you are seeking treatment & wellness care for?

What are your top areas of concern?

Thyroid

Perimenopause

Menopause

Weight Loss

Men's Health

Hormonal Imbalances

What are your BIGGEST obstacles to achieving your health goals?

Financial

Time - Too busy

Lack of Knowledge

Too Tired

Don't Know How to Exercise for Optimal Health

Don't Know How to Cook

Current medical treatment is not working well

Other - will discuss in call

What are you looking for most in a health care provider? (choose all that apply)

Listens to me

Looks at the big picture (holistic approach)

Collaborates with me to help me make the best health decisions for my circumstances

Looks for the root cause of my medical problems, instead of just addressing my symptoms

Do you have any questions that you want to be sure we address when we speak?

I understand Complete Health at Green Oaks PLLC does not use your insurance for weight loss and hormone therapy.

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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