Initial Client Survey Form
Please fill this form out prior to our discovery call so Walker's Functional Nutrition can learn more about your potential health concerns and goals.
First Name
Last Name
Email
Phone Number
What is your top challenge that you would like us to help you overcome?
Why is this goal important to you?
What is stopping you from accomplishing the above goal?
What are the characteristics that you value most in a healthcare partnership?
Do you have a supportive spouse, significant other, or friend to support your health goals?
yes
no
We’d love to know where you are located. If you live within the U.S., in what state or territory do you live?
Are you filling this survey out for yourself or on behalf of another person?
How did you find us or who referred you?
What are your main goals for seeking nutrition counseling with Walker's Functional Nutrition(Select all that apply
Support with a specific health condition (ie: Crohns, Rheumatoid Arthritis, gas)
Lose some weight, increase energy or just a general sense of I am not feeling as good as I could
I have been chronically ill for a long time and no one has been able to help me feel better
I was referred by another practitioner
Other (please specify)
Do you have any known health or medical conditions or diagnosis that we should know about in helping you to find the best care? If yes, please explain.
What have you tried so far to address your goal? (Diets, testing, modalities, etc.
Not much, just getting started
I’ve tried a few things, but I am overwhelmed by the information out there
I’ve been to more than 3 practitioners trying to figure this out
Other
Which of the following items are currently in your diet in any amount: (select all that apply)
Soda
diet soda
refined sugar
alcohol
fast food
Snack foods (chips, pretzels, etc.)
Dessert/candy (chocolate, cookies, candies, Twinkies, etc.
Gluten (wheat, rye, barley
Dairy (milk, cheese, yogurt)
Coffee
What percentage of your meals are currently home cooked?
Less than 25%
25-50%
50-70%
70-100%
Please let us know anything else about you, your goals for nutrition counseling with Walker's Functional Nutrition or your health aspirations.
What functional lab testing have you had done? (check all that apply)
Functional stool testing
Organic Acids testing
Genetic or Genomic testing
Hormone testing
Heavy Metals testing
None of the above
Are you willing do what’s necessary to reclaim your health? (for yourself no one else). This may include, dietary modifications, lifestyle and environmental modifications?
yes
no
I commit to move forward beyond any current limitations to achieve optimal health.
This is binding commitment to myself. I’m ready for positive change.
Submit
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