Wellness Blueprint Survey

**Disclaimer: I understand Health Restoration is not medical advice and we do not diagnose or treat diseases. We educate on how the body functions, we educate on proper lab testing, informed consent, and teach people to advocate for themselves**

First name

Last name

Email

Phone

What is your level of health?

Excellent

Good

Fair

Poor

Please list your most concerning health care problems at this time (in order of importance to you). 1:

2:

3:

4:

5:

When did your chief problem or illness begin?

What do you think caused your chief complaint?

Please list any notable current medications, previous surgeries, or medical events that may have contributed to the conditions listed above.

What is your goal for Health Restoration Coaching?

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