Free Wellness Questionnaire

Name *

First

Last

Email *

Preferred Phone *

What is your main health complaint? *

How often does it bother you? *

How long has it been going on? *

What is your Date of Birth *

What (or who) would prevent you from completing a health-rebuilding or weight loss program? *

What have you tried so far that has or has not worked? *

What is your current diet like? Please be specific: list breakfast, lunch, dinner, and snacks, as well as the times you eat. *

Are you taking any supplements or medications? Please list what you take and what it’s for. *

What would you like your health to be in 3 months from now? How about 6 months from now? *

What obstacles, challenges, and struggles do you face regarding diet/lifestyle? *

If we were to work together, what would you expect to achieve from working with me? *

What are 5 things you LOVE about your life? *

How did you hear about or find Sano Holistic Health? *

If you said Family/Friend Referral, let me know who specifically in the box below so I can thank them?

Any additional information?

This space is open for you to share any other important details you’d like me to know about before your consultation.

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*Your privacy matters! Your information will be kept confidential, that’s how it should be.

Prepping For Your FREE Wellness Consultation

As a Functional Diagnostic Nutrition (FDN) Practitioner and Massage Therapist, I teach clients a model of self-care that will relieve a variety of health complaints allowing the body to restore and improve overall well-being. Using a functional and holistic approach, I help uncover as many healing opportunities involved in the dysfunction or imbalance of the body.  Together we’ll work to restore balance in the body using a variety of tools to improve diet, rest, exercise, stress reduction and (natural) supplementation to promote the body’s innate healing process.

I don’t diagnose or treat any specific conditions or focus on symptoms.  I will help you to identify the underlying causes of stress on the body and then teach you a model of self-care that allows for natural and sustainable healing that will last your lifetime.  All recommendations are completely voluntary and designed to give you the power to choose what works best for your specific needs.