Dr. Herron's Health Assessment
Hello, and thank you for taking the time to touch base with me!  Please answer the following questions as truthfully as you can.  Your answers will help me select the best program for you based on your current health status, your daily habits, and what you want to achieve.  We have seven different health programs, which are customized to fit your personal goals and needs.  Once you have completed  this form, I can connect with you over the phone to go over your answers and discuss options. 

This should take you about 20 minutes to complete.

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Email *
Who gave you the link to this survey?  (In other words, who can we thank for referring you?!) *
In two or three sentences, please describe where you would like to be in your health:
 *
What outcomes are most important to you? (Pick up to 3)
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Required
When was the last time you remember feeling healthy?  What did that feel like, and how would it feel to be back there again?
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What is your main motivation for wanting to change? What sorts of things do you wish you could do if you were able to attain your health goals?
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How ready are you to make significant changes in your life in order to achieve your health goals?
 *
Not ready, I am comfortable where I am
Extremely ready, I can't be in this place anymore
If you didn't pick #10 for the question above, could you explain why?
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As you work towards getting healthy, can you think of anyone in your life who might want to join you?
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