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Question 1 of 19
Name (First, Last)
Question 2 of 19
Complete Address (Street, City, State, and Zip Code)
Question 3 of 19
Best Contact Phone
Question 4 of 19
Date of Birth
Question 5 of 19
How did you hear about Dr. Buttler?
Question 6 of 19
Question 7 of 19
Question 8 of 19
Are you taking any prescription pharmaceutical medications? (please do not list supplements, only prescribed medications)
Question 9 of 19
How long have you been experiencing your symptoms?
<6 months
6-12 months
1-3 years
3+ years
Question 10 of 19
Question 11 of 19
Question 12 of 19
What role do you want Dr.Buttler to play in your healthcare? (i.e., general health advice, someone to create a specific treatment plan to recover my health, someone to manage my labs and medications, etc.)
Question 13 of 19
Are you willing to change your diet?
Yes
No
Question 14 of 19
Question 15 of 19
Question 16 of 19
<$500
$500-$1000
I'm priceless
Question 17 of 19
On a scale of 1-10 (1= I do not want to change anything, and 10= I am willing to change anything and everything if needed), how committed are you to addressing the underlying cause of your health concerns?
1
2
3
4
5
6
7
8
9
10
Question 18 of 19
Is there anyone else involved in your health and financial decision-making process? (i.e. spouse, family member, etc)
No, just me.
Yes, I have another family member I need to consult with before making this decision.
Question 19 of 19
For fun, if you could have dinner with 2 people (not family) alive or dead, who would they be?