First Name
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Last Name
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Confirm Email
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Confirm Contact Number
What are the main health concerns or symptoms you're currently dealing with?
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How long have you been dealing with these issues?
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Less than 3 months
3–12 months
1–3 years
Over 3 years
How are these issues affecting your daily life?
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What have you already tried to improve your symptoms?
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What would your life look like if you could resolve these issues in the next 6–12 months?
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How committed are you to making your health a top priority right now?
100% ready — I’ve tried enough and I’m done guessing
Somewhat ready — I want help but still doing research
Just curious — I’m not ready to take action yet
Are you open to investing time, energy, and financial resources into your health if we find that you're a good fit for our program?
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Yes, absolutely
Possibly — it depends on the program
No — I’m not in a place to invest right now
Who have you worked with to try to fix this?
Medical Doctor (MD / DO)
Naturopathic Doctor (ND)
Functional Medicine Practitioner
Nutritionist / Dietitian
Chiropractor
Acupuncturist / TCM Practitioner
Health Coach
Other
What’s your biggest concern or fear about starting a new health program?
Why do you feel now is the right time to make a change?
On a scale of 1–10, how important is it for you to get to the root cause of your health issues? 1 = Not important / 10 = Extremely important
Is there anything else you'd like us to know before your call?
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