HEAL ENDO - INITIAL CONSULTATION FORM

Thanks so much for taking the time to fill out this form. I'm very much looking forward to getting to know you and fully understand your own, unique situation.

Name *
Name
GENERAL HEALTH
Please list all below including name brands and amounts
The Following Health Complications Run in My Famliy (check as needed)
MENSTRUATION
FERTILITY
ENDOMETRIOSIS - If not applicable, please skip to next section
Ultrasound, etc
Have you had any of the following organs removed?
PAIN WITH SEX:
PAIN WITH BOWEL MOVEMENT
Other Pain
Systemic symptoms
PERSONAL PREFERENCES FOR HEALING
Tell me how you best adopt changes so I can help create the best plan for you: All at once/full throttle, baby steps, moderate, etc
Tell me your thoughts: have never tried, have tried it all, am willing and open, am hesitant, etc
Tell me your thoughts: have never tried, have tried it all, am willing and open, am hesitant, etc
Tell me your thoughts: hate/won't ever take, will consider in moderation, want the full assortment, etc.
Tell me a little bit about what inspires you to heal. How do you imagine your life would be if you tackled your main health issues?