New Patient Questionnaire - Denver Naturopathic Clinic | Healing Roots |Denver Naturopathic Clinic

Name*

First Last

Phone*

Email*

In what state do you primarily reside?*

Briefly, what are your top three health concerns?*

Briefly, how are these issues impacting your life currently?*

How committed are you on a 1 to 10 scale to resolving these issues and transforming your health?*

10 is the highest commitment level.

Do you have any additional health goals? Check all that apply:*

These additional goals represent the types of “side benefits” committed patients have experienced in working with Dr. Enos.

Can you see yourself committing your resources of time, energy and finances for the next 7 to 14 months to support you in your healing goals?*

Are you willing to make individualized lifestyle and dietary changes?*

Are you willing to take supplements or remedies in cap, powder, pellet and liquid forms 2-3 times per day?*

What are the top three qualities you are looking for a in a doctor-patient relationship?*

Are you currently pregnant?*

Are you planning to conceive in the next 7-14 months?*

How did you hear about us? Choose all that apply:*

Referred to:*

Referred by:*

Thank You!! We will contact you within the next week.

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