Life Impact Survey
Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Do you suffer from any of the following?
*
Weight Gain
Fatigue
Hormone Problems
Digestive Problems
Anxiety
Depression
Other
Please describe your particular problem(s) specifically:
*
When did this first begin?
*
Have you seen any other healthcare providers for this?
*
Please Select
Yes
No
If yes, who else have you seen?
What other treatment approaches have you tried already?
*
On a scale of 0-10 (0 being no problem at all, 10 being worst possible), how would you rate your health problem(s)?
*
On a scale of 0-10 (0 being not motivated at all, 10 being very highly motivated), how would you rate your level of motivation to fix your problem(s)?
*
Do you have any concerns that you'd like to discuss that you feel would keep you from getting help?
*
Submit
Should be Empty: