JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Free Consult Form
complimentary phone consult questionnaire
Sign in to Google
to save your progress.
Learn more
* Indicates required question
First & Last Name
*
Your answer
Age
*
Your answer
email
*
Your answer
Phone number
*
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Country
*
Your answer
How Did You Hear About Dr. Linda
*
Your answer
What is Your Main Health Concern?
*
Your answer
When Did It Start?
*
Your answer
On a 1-100 scale (100 being very healthy & 1 very unhealthy) where do you rank your health?
*
Your answer
Where do you want your health to be on a 1-100 scale (1=poor 100=excellent health)
*
Your answer
How long do you think it will take you to get to your health goal stated above?
*
Your answer
What are some areas in your life (work, home, sex, relationships, travel, every day activities) that are affected because of your current health condition/status? What health concerns are keeping you up at night, or from living the best life?
*
Your answer
What is your single biggest challenge that is holding you back from feeling healthy, vibrant and the best version of YOU right now?
*
Your answer
What are the top three things you would like to change or make better in the next 3 months in regards to your health?
*
Your answer
How would your life be if this change happened (example: I would be able to play with kids, I would be able to travel more)
*
Your answer
If you transformed your health, how would that make you feel?
*
Your answer
When you have tired to change before, what happened? What has held you back? What blocks have kept you from changing?
*
Your answer
Why are you interested in having someone help you with your current health issues?
*
Your answer
How willing are you to invest in yourself and what types of things have you done before?
*
Your answer
Why is it important to change now?
*
Your answer
On a scale of 1-100 (1=not very important 100=very important), how important is this to you?
*
Your answer
What kind of support is most helpful to you?
*
Your answer
How will you know how effective our engagement has been?
*
Your answer
What specifically would you like to talk about during this strategy session?
*
Your answer
What single action can you take now that would help you with your current health issues and that you haven't done already, yet you know if you just did it, it would change your current health issue dramatically?
*
Your answer
How willing are you to make substantial changes to your thinking, behavior, and actions?
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Help Forms improve
Report