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dmgweb
2022-12-22T20:25:50+00:00
Questionnaire
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First Name
Last Name
Email Address
Phone Number
Sex
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Male
Female
Other
Which of these symptoms, if any, do you experience frequently?
Gas, bloating, constipation, diarrhea, or discomfort in the belly
Joint pain, muscle spasms or weakness
Anxiety or depression
Sleeplessness or waking up unrefreshed
Lack of energy to do the things you love
Sensitivity to smells around you
Environmental allergies or asthma
Cold hands or feet
Thinning head hair, weight gain (or difficulty losing weight), or dry skin
Infections, colds, or flu
Sugar or carb cravings, fatigue after eating
Increased thirst or urination
PMS- physical or emotional (headaches, irritability, mood swings, bloating, etc)
Cravings for salt or junk food
Feeling wired and tired at the same time
Ovarian cysts or PCOS
Irregular menstrual cycles (or you have in the past)
Heavy bleeding or scanty bleeding
Endometriosis or painful periods
Excess hair on your face, chest, or arms
Hyper or hypoglycemia intolerance to heat or cold
Low sex drive
Enlarged thyroid gland, difficulty swallowing, or enlarged tongue
Slow brain, slow thoughts, or difficulty concentrating
Food allergies known or suspect, reactions to foods
Slow reflexes or slowed reaction time
Family history of thyroid problems
Fatigue or sluggishness
Acne or unhealthy skin
Waist girth equal or larger than hip girth
New mom with fatigue, depression, finding it difficult to lose weight since giving birth
Weight loss issues
On a scale of 1-10, 1 being not very committed to 10 being super committed, how committed are you to changing your health?*
What kind of support are you looking for right now? What do you feel is your biggest health challenge? *
I agree to having a strong interest in enrolling into a program.*
Yes
No
I understand Dr. Rachelle's practice is direct pay/cash-based only. FSA and HSA are acceptable, however if provided in debit card.
*
Yes
No
I understand Dr. Rachelle is not contracted with health insurance.
*
Yes
No
There is a $1000 minimum to enroll in our concierge programs.
*
I understand my health is priceless and I have the financial resources to retain concierge medical services with Dr. Rachelle.
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