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?* 1 2 3 4 5 6 7 8 9 1010 is the highest commitment level.Do you have any additional health goals? Check all that apply:* Increase energy Reduce fatigue Prevent future disease Anti-aging Maintain a healthy life longer Eliminate dependence on over-the-counter medications Sleep more soundly Improve skin quality Improve hair and nail health Increase endurance Improve sex drive Eliminate allergies Be free of pain Lose weight Gain weight Maintain my current weight Increase flexibility Increase muscle strength Increase muscle tone Learn to reduce stress Increase mental focus Improve memory Reduce depression Stabilize moods Be more decisive Be more motivated Shift from treating illness to creating and optimizing wellness Learn habits to keep you healthy and prevent disease Learn to listen to and understand the cues from your bodyThese 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?* Yes No MaybeAre you willing to make individualized lifestyle and dietary changes?* Yes No It dependsAre you willing to take supplements or remedies in cap, powder, pellet and liquid forms 2-3 times per day?* Yes NoWhat are the top three qualities you are looking for a in a doctor-patient relationship?*1. 2. 3.Are you currently pregnant?* Yes NoAre you planning to conceive in the next 7-14 months?* Yes NoHow did you hear about us? Choose all that apply:* Practitioner Referral Friend/family Referral Internet Search Yelp Google Reviews Office SignageReferred to:* Dr. Enos Dr. SchiefereckeReferred by:* Thank You!! We will contact you within the next week.CAPTCHAΔ
