Reboot Center Initial Free Empowered Wellness Consultation Form

START YOUR EMPOWERED WELLNESS JOURNEY TODAY

Step 1: Answer the following questions and submit.
Step 2: Pick a time on Dr. Jennifer’s calendar for your Initial Free Consult. Please commit to this time.
Step 3: During the Initial Complimentary Health Strategy Session, you’ll find out if you’re a good candidate for the EW Program. If you are, Dr. Jennifer will lead you through the next steps.

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PART I

Name*

Age Range*

Sex*

Phone*

Email*

Please list your 3 major health concerns in order of importance:

PART II

Your first step towards better health begins with this simple questionnaire. Please pick the most appropriate number for the next 10 questions. 0 as the least/never, and 3 as the most/always.

Pass large amounts of foul-smelling gas*

Frequent bloating after eating*

Heartburn or reflux after eating*

Alternating constipation and diarrhea*

Acne and unhealthy skin*

Crave sweets during the day*

Irritable, agitated, easily upset*

Slow starter most mornings*

Tired/sluggish during day*

Depression/lack of motivation*

PART III

Please pick the most appropriate number for the next 4 questions. 1 as the least/never, and 10 as the most/always.

How important is it for you to resolve your health concerns?*

Do you feel that you are coachable & would enjoy a personal health coach?*

Are you prepared to make the appropriate lifestyle changes that may be necessary in order to achieve your goals?*

How important is it for you to address your health through diet, lifestyle & nutrition instead of masking symptoms?*

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START YOUR EMPOWERED WELLNESS JOURNEY TODAY

PART I

PART II

PART III

Reboot Center for Innovative Medicine

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