Patient Profile Form

  1. This should take you approximately 10-15 minutes to complete. Please answer thoroughly and honestly and give the questions due consideration.
  2. (required)
  3. (valid email required)
  4. (required)
  5. (required)
  6. (required)
  7. (required)
  8. (required)
  9. (required)
  10. (required)
  11. 1. How did you hear about Sari's Natural Medicine?

  12. (required)
  13. (required)
  14. (required)
  15. 5. How motivated and committed are you to improving your health? Please select a number from 1 (not committed) and 10 (very committed).

  16. (required)
  17. (required)
  18. (required)
  19. (required)
  20. (required)
  21. 13. Please rate the following on a scale of 1 (poor) and 5 (excellent).
  22. General health and wellbeing
  23. Overall quality of your diet
  24. Sense of calm and relaxation
  25. Quality and quantity of sleep
  26. Exercise and general activity levels
  27. 14. To improve your health and wellbeing you may be asked to make some changes to your diet and /or lifestyle. If requested to do so, how willing would you be to do the following? Please rate on a scale of 1 (not willing at all), to 5 (extremely willing).
  28. Significantly modify your diet:
  29. Engage in regular exercise/ activity:
  30. Practice relaxation techniques on a regular basis:
  31. Modify your sleep habits:
  32. Have consultations to assess your progress:
  33. Thank you. I look forward to working together with you to help you reach your health potential.