New Patient Inquiry Form
Because our practice strives to provide the best one-on-one and personalized care tailored to your individual needs, we are able to support and intake a maximum of ten new patient programs per month. Kindly fill out our questionnaire so that we may learn about you as it relates to our program offerings.
Email address *
Name *
Your answer
Cell Phone *
Your answer
Gender *
Your answer
Date of birth *
How did you hear about us? *
If referral, by whom?
Your answer
If other, how did you hear about us?
Your answer
Have you heard our ad on WUNC radio?
Please describe the nature of your health concerns. *
Your answer
How long have these health concerns been active? *
Your answer
Have you become discouraged or distressed by these health problems? *
Your answer
Do your health problems affect your...
(severity on a scale from 0 to 10, with 0 the least and 10 the most)
Work *
Family life *
Recreational activities *
Sexual function *
Relationships with friends *
What factors do you believe have contributed to creating these health issues? *
Your answer
Left untended, where do you anticipate these health problems will take you? How do you imagine your life in 3-5 years if these health issues are not addressed? *
Your answer
What are your goals in working with Dr. Sharp (limited/short-term/resolution of symptoms or more holistic functional goals including lifestyle modifications and wellness)? *
Your answer
Are there specific health concerns you are concerned might arise from these health problems if not addressed (perhaps because of family history)? Examples might include dementia, cancer, heart disease, diabetes, autoimmune. Please list them. *
Your answer
What are your most cherished life goals that your health issues may prevent you from achieving? Dream big! What barriers exist that you feel may prevent you from achieving your goals? What strengths or assets can you call upon to help you achieve your goals? *
Your answer
How would you rate the importance of resolving your health problems? *
How open are you to being coached? *
How ready are you to make lifestyle changes to help you improve your health? *
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