iPlanet Health Wellness Questionnaire
Thank You for Filling Out This Questionnaire from the practice of Dr. Hale, AP, owner of iPlanet Health
This is a complimentary service. You are under no obligation. Please call us at 561-337-9435 if you have questions
PLEASE NOTE: FILLING OUT THIS QUESTIONNAIRE IS NECESSARY IN ORDER TO PURCHASE PRODUCTS FROM CERTAIN BRANDS ON OUR WEBSITE. DISCLAIMER: THIS IS NOT A MEDICAL HISTORY
Brought to you from the practice of Dr. Hale, AP
1. How is your health statis? *
2. Do you take nutritional supplements? *
If you like, you can list some of the supplements you are presently taking (optional)
Your answer
If you are interested in a particular Brand of products - please indicate which Brand (answering this field can help us to approve your account more quickly)
Your answer
3. Do you take other medications? *
If you like, you can list some of the medications you are presently taking (optional)
Your answer
4. Are you presently getting advice from a practitioner regarding supplements? *
It is helpful for us to have the name of your practitioner for our files. (We don't contact your doctor. This answer is optional but for the purchase of some Brands is required. )
Your answer
5. Do you exercise on a weekly basis? *
6. Do you enjoy any of the following exercises?
Other (please specify)
Your answer
7. Would you like to comment on your diet?
Your answer
8. Please feel free to provide Dr. Hale, AP with some of your wellness goals. He is happy to provide suggestions. You are encouraged to take advantage of his yrs of experience and his diverse background.
Your answer
9. In order for us to complete your Wellness client status, Please provide some basic contact info. Name and Email is required.
Your answer
Name *
Your answer
Email Address - please make sure your email address is correct. *
Your answer
Phone (optional)
Your answer
By filling out this questionnaire - I am authorizing Dr. Hale, AP to be part of my advisory Well-Care team. I understand that I can contact Dr. Hale, AP via phone or email if I need product or general wellness advice. (Please note: We don't share your personal information and you will not be solicited). Please provide your consent by typing your initials in the answer field below ->
Your answer
New Customers: You are entitled as a Wellness Client to a complimentary 10-15 minute phone consultation or the equivalent in correspondence via email). Give us a call and if Dr. Hale, AP is available he would be happy to talk with you (if he is busy then you can schedule a call back time) Our office number is 561-337-9435.Our business hours are 10-5 M-F EST - After hrs please leave a message.
MM
/
DD
/
YYYY
Thank you for filling out our Wellness Questionnaire.
We look forward to be of assistance to you on your journey to greater wellness! Dr. Hale
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.