Wellness Survey
Step 1-  Complete this form before scheduling your complementary Curiosity Call with Functional Health & Wellness Practitioner, Alejandra Garcia. Please take your time completing this form. This will make for a highly efficient call and allow me to add more value to our conversation.

Step 2- Use this booking link to schedule your Curiosity Call, a 30 minute Zoom call that's all about YOU! 
I will devote my time to explore what's been going on with you and we'll discuss your biggest health concerns and goals so that you can take back control of your health and give back to the world!

I thank you for being here and appreciate you investing your time and prioritizing your health! 
(Note: Existing clients do not qualify for this free call.)

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Email *
First and last name:
Preferred Phone *
Birthday *
MM
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DD
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YYYY
What do you do for work? *
How many work hours per week?
What are your main health concerns?  This may be a diagnosis or a collection of symptoms. *
How often does it bother you? *
How long has it been going on? *
What has been the biggest obstacle in hitting your health goals?  Try to determine the MAIN thing that is holding you back. For some people, it's financial constraints, for others it might be unsupportive family members. Or, it might be very personal reasons like feeling powerless, have zero will-power, or dealing with an addiction (food, substances, unhealthy lifestyle behaviors). *
What is your current diet like? Please be specific: list breakfast, lunch, dinner and snacks, as well as the times you eat. *
What additional obstacles, challenges, and struggles do you face regarding diet/ lifestyle? *
How much have you invested in your health so far? What was the result? *
What would you like your health to be in 3 months from now?  How about 6 months from now? *
If we were to work together, what would you expect to learn in working with me? *
What are 5 things you LOVE about your life? *
On a scale of 1 to 5, how committed are you to improving your health? *
Not Committed
Fully Committed
I want to get expert health tips, health and home care product recommendations, wellness resources and products specials in a weekly newsletter. *
A copy of your responses will be emailed to the address you provided.
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