NourishMint Wellness Health Strategy Session Intake Form

Name

Email Address

Phone Number

What is your biggest health concern

How are you currently trying to remedy and work on this concern?

What would be different in your life if your main concern disappeared?

What could potentially happen in your life if you didn't address this health concern?

What are your top 3 health and wellness goals for this year?

Which of the following have you worked with in the past? Holistic Nutritionist / Chiropractor / Acupuncturist / Medical Doctor / Other ______________

What have you tried in the past that hasn't worked?

What have you tried that has worked?

Are you hoping for a quick fix, or do you understand that finding the root cause of a condition can take time?

Does exercise play a current roll in your life?

What is your commitment level (1 to 10)?

What is your budget for your health?

Are you ready and prepared to invest the time, energy, and money to work towards and support your current health concerns?

Are you open to a supplement protocol of suggested lab tests?

Anything else you would like me to know?