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Readiness Quiz
Hi there, please complete your details and answer these questions to help us understand your needs.We will then send you some information about the practice.
12
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1
Email
*
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example@example.com
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2
Your name
*
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First Name
Last Name
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3
Phone Number
*
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Area Code
Phone Number
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4
Are you willing to complete a detailed history online at your own pace to enable your practitioner to do your Functional Medicine Analysis?
*
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Yes, no problem.
Unsure, I am not confident with computers.
No, I don't have access to the internet. I need a paper based questionnaire.
Yes, no problem.
Unsure, I am not confident with computers.
No, I don't have access to the internet. I need a paper based questionnaire.
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5
Are you willing to do functional testing at home plus blood testing at the clinic if required?
*
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Yes when provided with video and written instructions.
Yes but I would need further support from a relative.
No I do not want to do testing at home.
Yes when provided with video and written instructions.
Yes but I would need further support from a relative.
No I do not want to do testing at home.
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6
I am willing to change what I eat in order to improve my health.
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7
I am open and willing to adding supplements to my diet to correct deficiencies or imbalances which will assist with improving my health.
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8
I would be willing to alter my lifestyle to improve my health e.g. reduce alcohol, learn relaxation techniques etc.
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9
I am willing to increase my activity level and do moderate exercise to improve my health.
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10
I would accept advice about how to reduce stress in my life.
*
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11
I am willing to spend money on advanced testing, supplements and the clinic's services to improve my health. I am able to invest:
*
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$500-1500
$1500 - 2500
$2500-5000
Whatever it takes
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12
If you know who your preferred practitioner would be, please tick the appropriate box below.
*
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Dr Leigh Willoughby
Amanda Roe ND
Gawain Fraser
No preference
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