First Name

Last Name

Phone *

Email *

Country

Are you willing to complete a detailed history online at your own pace to enable your practitioner to do your Functional Medicine Analysis?

Are you willing to do functional testing at home plus blood testing at the clinic if required?

I am willing to change what I eat in order to improve my health.

Extremely willing

Somewhat willing

Not willing

I am open and willing to adding supplements to my diet to correct deficiencies or imbalances which will assist with improving my health.

Yes

I would be willing to alter my lifestyle to improve my health e.g. reduce alcohol, learn relaxation techniques etc.

Yes

I am willing to increase my activity level and do moderate exercise to improve my health.

Yes

I would accept advice about how to reduce stress in my life.

Yes

Do you consider yourself coachable?

Yes

Do you understand that our clinic is a private practice (fee for service)?

Yes

I am willing to spend money on advanced testing, supplements and the clinic's services to improve my health. I am able to invest:

Whatever it takes

$2500-5000

$1500-2500

$500-1500

If you know who your preferred practitioner would be, please tick the appropriate box below.

Dr Leigh Willoughby

Gawain Fraser

Amanda Roe ND

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