Functional Medicine Readiness Questionnaire

  • 54321
    Significantly modify your diet
    Take several nutritional supplements each day
    Keep a record of everything you eat each day
    Modify your lifestyle (e.g. work demands, sleep habits)
    Practice a relaxation technique
    Engage in regular exercise
  • 54321
    How confident are you in your ability to organize and follow through on the above-related health activities
  • 54321
    At the present time, how supportive do you think the people in your household will be to your implementing the above changes?
  • 54321
    How much ongoing support (e.g. telephone consults, email correspondence) from our professional staff would be helpful to uyou as you implement your personal health program?