Rethink Food ~ Rethink Health
This short survey allow me to get a snapshot of your needs and desires for nutrition counseling services. Upon completion of the survey you'll be able to schedule a complimentary Strategy Session with me, a Functional Nutrition Counselor to discuss how I can best help you.
Are you ready for a fully support health transformation? It starts here!!
What is your name (first and last please)
What email address may I use to contact you?
I would love to know where you are located? (city and state)
Are you filling this survey out for yourself or on behalf of another person?
For another person (please note relationship)
I would love to know how you found me, where you referred?
What is your main goals for seeking nutrition counseling with me?
Support with a specific health condition (i.e. Crohn's Rheumatoid Arthritis, gas)
Lost weight, increase energy, or just a general sense of "I am not feeling as good as I could"
I have been chronically ill for a long time and no one has been able to help me feel better
I was referred by another practitioner
Do you have any known health or medical conditions or diagnosis that I should know about in helping you find the best care? If yes, please explain.
What have you tried so far to address your goal? (diets, testing, modalities, etc.)
Not much just getting started
I've tried a few things, but I am overwhelmed by the information out there.
I've been to more than 3 practitioners trying to figure this out, and understanding or relief is still a mystery.
Which of the following items are currently in your diet in any amount? (select all that apply)
Snack foods (chips, pretzels, etc)
Dessert/candy (chocolate, cookies, candies, Twinkies, etc)
Gluten (wheat, rye, barley, spelt)
Diary (milk, cheese, yogurt)
What percentage of your meals are currently cooked at home?
Less than 25%
Please let me know anything else about you, your goals, for nutrition counseling with Rethink Food ~ Rethink Health or your health aspirations.
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