Health Goals and Objectives

Health Goals & Objectives
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Welcome to Fresh Fit Consulting!

In order to gain a better understanding of your overall health goals and objectives we would like to ask you to answer the following questions. Answer to the best of your ability without overtinking. This is not a test!
My first priority for scheduling this consultation is:*
A secondary concern for me is:
As a patient, I am more interested in:*

Education, of present health statusTreatment, of existing or likely to be diagnosed conditions
Given the opportunity to design your own treatment, which approach sounds most appealing:*

A Self Service approach, designed to allow patients to pick and choose individual options at their own speedA Structured all inclusive approach, designed to foster adherence and treatment success
How would you prioritize the following considerations as they apply to your individual care. (Reorder the following options so that your highest priority is #1 and your lowest is #3)
Which of these statements best describe you? (Choose a maximum of 3)*

I already have a Primary Care Physician and/or am looking for treatment outside of insurance coverageI am not currently ready to consider services and treatment outside of insurance coverageI want to take as few medications as possible and am ready to make personal lifestyle changes to reach this goalI have immediate concern regarding the status of a preexisting conditionI am nervous as to how my family medical history will impact me as I continue to ageI want to explore advanced specialty testing for my hormones, GI tract, and/or metabolic function, understanding that these tests will incur laboratory and interpretation fees outside the scope of insurance coverage.I have trouble focusing during the day, struggle to complete tasks on time, and experience difficulty with personal motivationI can't sleep, I have trouble falling or staying asleep, or just feel tired more often than notMy snoring is out of control and is negatively impacting my relationship with my partnerI need to lose weight and am ready to make committed changes to my current lifestyle in order to reach this goalMy problems are so complicated that I don't know who to turn to, I have seen multiple other doctors with little success and have lost faith in the traditional medical systemI am looking for expanded personal physician services/attention outside of regular appointments
I am currently taking the following medications:
I am currently taking the following supplements:
In the past I have unsuccessfully attempted the following treatments:
Any additional comments, concerns, or things we should know?
Should be Empty:

Health Goals & Objectives