Pre-Appointment Questionnaire
Good job. Taking the time to fill out this application shows you are dedicated to taking care of your health. I look forward to speaking with you. Your answers will help make your call with me more efficient. **The boxes can expand so write as much as you need to fill out each question completely.**
List your NAME + EMAIL + PHONE # -- We are asking for this because we cannot contact you without it. (Please don't be one of the few who fill this out but don't leave any contact info!) *
Your answer
How did you hear hear about this opportunity? *
Your answer
Your Diabetes History
What kind of diabetes do you have? *
At what age were you diagnosed? What is your age now? *
Your answer
Do you do shots or pump? Please describe your daily insulin regimen and list total daily dose if on pump. *
Your answer
Do you have a Continuous Glucose Monitor? If not, how many times a day do you check your blood sugar? *
Your answer
What was your last Hemoglobin A1c (HbA1c)? *
Your answer
What are the top 2-3 questions you have? What is your biggest challenge living with diabetes? What do you think you need to help improve your health? *
Your answer
Your Dietary Habits
What do you tend to eat for breakfast? lunch? dinner? snacks? PLEASE LIST AN ANSWER FOR EACH. Do you have any issues or habits around food that you struggle with? (The box expands so there is as much room as you need to complete this answer in full.) *
Your answer
Your Exercise Habits
What do you do for exercise? Frequency? Are you at where you'd like to be physically? If not, what are your challenges? *
Your answer
Your Sleep Habits
Are you satisfied with the amount of sleep you get? and the quality? Any improvements you'd like to make here? *
Your answer
Your Overall Outlook
Describe your overall outlook on diabetes? on your life? on yourself? How does diabetes impact your life?In what ways would you like to improve your emotional health? *
Your answer
Your Readiness to Make a Change
How ready are you energetically to do whatever it takes to make lasting positive changes in your health and your life? 1 = no interest in changing; 5 = I'm ready! *
Your answer
How ready are you financially to do whatever it takes to make lasting positive changes in your health and your life? 1 = no way; 5 = Very Possible
Your answer
CONGRATULATIONS!
(You are not done yet! Be sure to scroll to the bottom and click on 'submit' before you leave this page, or else your answers will not be saved.) By investing the time to fill out this application, you've taken a significant step towards improving your life with diabetes and having more joy and happiness in your life. If you haven't already done so, your next step is to copy this link to schedule your call (after you click on 'submit' below!): https://calendly.com/drjodynd/complimentary-intro-call-20-min Please note, this call is not about giving medical advice. The purpose is for us to get to know each other a bit...for me to learn how you'd like to improve your health and for you to get a feel for who I am and decide if you'd like for me to help you. Diabetes is a condition that needs serious attention. If you're A1c is above 6.5%, you are missing out on being able to be much happier and healthier, and I don't suggest putting this off. I can help you get on the right track. If you are not ready to take action, please schedule this call at a later date when you are ready. If you are tired of not feeling well and ready to TAKE ACTION toward having the happy and healthy life you deserve, I look forward to speaking with you! - Dr. Jody Stanislaw
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