Intake Form | lifestylemedicinesarasota.com

1. Please enter your information.

First Name:

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Last Name:

Date of Birth:

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Street Address:

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2. What is your question? What problem has prompted you to reach out for assistance ?

3. How long have you had this issue or concern?

4. What habits, behaviors or circumstances do you believe contributed to this problem?

5. What have you done so far to address this?

6. Why do you want to solve this issue/problem?

7. HOW READY ARE YOU -TO SOLVE THIS PROBLEM? (on a scale from 1-10) 1- I wish the problem would dispear -I'm too busy I to invest time, money or effort to solve it right now. 5 -I am ready to learn more about this problem. I could budget for the solution if needed. 10- I have ideas on what caused this problem. I am ready to invest time, money and effort to solve it for good.

8. What are the TOP 3 priorities in your life for the next 12 months? 1= HIGHEST priority 10= LOWEST priority this coming year Where does HEALTH rank in priority in your life for the coming 12 months?

9. Do you have the TIME (weekly or monthly) and MONEY (budget) set aside to solve this problem?

10. How much money did you spend or invest in upleveling the status of your own health last year?

11. How did you hear about us?

12. Dr. Ashby will reach out to schedule a free introductory conversation.

13. If you are unable to work with Dr. Ashby at this time -she can still enrich and empower your health journey; would you like her to share those occasional health improvement opportunities with you?

Yes
No

14. Please attach file that you and Dr. Ashby plan to review here

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