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Margaret Kimura
Holistic Health Strategist
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Health Questionaire
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Name
*
First
Last
Email
*
Phone
Birthdate
Symptoms and Diagnosis
What is the biggest issue you are facing at this time?
Why are you choosing holistic level care?
How committed are you to healing your body at the cellular level
Select One
1
2
3
4
6
6
7
8
9
10
Do you have previous experience working with functional medicine?
Select One
Yes
No
If no, why are you coming to a holistic practitioner
Motivation and Commitment: In a few sentences, please explain why you are interested in functional medicine at this time and why you would be a good fit at this time?
Interpersonal Skills: Describe your ability to commit 100% to your health at this time?
Are you comfortable working in a team environment, with a diverse group of individuals?
Select One
Yes
No
Following Protocols: Provide an example of a challenging situation you faced and how you resolved it.
Time Management: Give an example of how you manage your time and prioritize tasks.
Are you financially prepared to invest in your health?
Select One
Yes
No
Is there any other information you would like to share with us that you believe would support your application?
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