Dr. Terra Winston's Prospective Patient Application
Pre-screening form
Email *
Name (First and Last) *
Best contact phone: *
Date of Birth *
How did you find Dr. Terra Winston?
In what state do you currently live? (Please note: Dr. Winston is not seeing international patients at this time) *
What are you looking for help with? *
Required
Please list briefly what you're looking for help with (i.e. "irregular periods," "just diagnosed with lyme disease," "thyroid disorder," etc) *
Do you have any medical conditions Dr. Winston should be aware of? If so, what are they? *
Are you taking any pharmaceutical medications? (prescribed meds only, not supplements) please list them: *
How long have you been experiencing symptoms? *
Required
Have you ever worked with another practitioner for this issue? *
Required
If yes, please explain more.
In an ideal world, describe what your health will look like 6 months from now (try to get specific, i.e. "I will have regular periods, no more acne, and feel energetic")
Please rate your overall health (1= I am often sick and have a lot of health concerns, 5= I'm feeling the best I've ever felt!) * *
What do you want most from Dr. Winston?(i.e. general health advise, someone to hold me accountable in undertaking my lifestyle change, someone to manage labs and meditations, etc.)
Do you currently follow an exercise routine? If so, please describe. If no, are you willing to begin one that is tailored to you and your current abilities?
Your health is an investment! How much are you willing to invest in your health per month? *
On a scale of 1-10 (1= I don't want to change anything, and 10= I am willing to change anything and everything if needed), how committed are you to improving your health right now?
Clear selection
Is there anyone else involved in your health and financial decision-making process?(spouse, family member, etc)
Clear selection
If you could only eat one thing for the rest of your life, what would it be? (this is just for fun!)
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