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Prospective Patient Application~Dr. Terra Winston N.D

Welcome!

My passion is helping people finally uncover the ROOT CAUSE of their symptoms so they can enjoy a long, pain-free and energized life!

Want to find out if my approach is right for you? Fill out this brief application and my team will be in touch!

Can't wait to meet you!

-Dr. Terra

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Question 1 of 21

NAME: (FIRST, LAST)

Question 2 of 21

EMAIL ADDRESS:

Question 3 of 21

MAILING ADDRESS

Question 4 of 21

IN WHAT STATE DO YOU CURRENTLY RESIDE?

Question 5 of 21

BEST CONTACT PHONE NUMBER

Question 6 of 21

DATE OF BIRTH

Question 7 of 21

HOW DID YOU FIND DR. TERRA?

Question 8 of 21

WHAT SPECIFIC HEALTH GOALS WOULD YOU LIKE TO WORK ON WITH DR TERRA? 

Question 9 of 21

WHAT WOULD NEED TO HAPPEN IN THE NEXT 3-6 MONTHS IN ORDER FOR YOU TO FEEL SATISFIED WITH YOUR PROGRESS?

Question 10 of 21

WHERE DO YOU FEEL STUCK ON YOUR CURRENT PATH?

Question 11 of 21

IN A PERFECT WORLD, IF COST WASN'T AN ISSUE, WHAT SPECIFIC SUPPORT WOULD YOU LIKE ? (ie, accountability, meal planning, 1:1 care, medication and supplement recommendations, physical medicine, etc?)

Question 12 of 21

IN WHAT WAY IS YOUR CURRENT PAIN OR CONDITION AFFECTING YOUR LIFE? (Are there things you can't or don't want to do because of your condition? Are others in your life affected by your condition?)

Question 13 of 21

HOW LONG HAVE YOU BEEN EXPERIENCING SYMPTOMS?

A

<6 MONTHS

B

6 -12 MONTHS

C

1 - 3 YEARS

D

3+ YEARS

Question 14 of 21

HAVE YOU WORKED WITH ANOTHER PRACTITIONER FOR THIS ISSUE?

A

YES

B

NO

Question 15 of 21

IF YES, PLEASE DESCRIBE

Question 16 of 21

PLEASE RATE YOUR OVERALL HEALTH. (1=I AM OFTEN SICK AND HAVE SEVERAL HEALTH CONCERNS, 5=I'M FEELING THE BEST I'VE EVER FELT!)

A

1

B

2

C

3

D

4

E

5

Question 17 of 21

DO YOU HAVE ANY MEDICAL CONDITIONS DR. TERRA SHOULD BE AWARE OF?

Question 18 of 21

ARE YOU WILLING TO INVEST IN YOUR HEALTH NOW, SO YOU CAN HAVE LESS MEDICAL EXPENSES AND MORE TIME AND ENERGY IN THE FUTURE?

 

*PLEASE NOTE: DR. TERRA WINSTON DOES NOT BILL INSURANCE, HOWEVER YOUR INSURANCE MAY BE USED TO COVER THE COST OF LABS AND MEDICATIONS WHEN APPROPRIATE. YOU ARE WELCOME TO SELF-SUBMIT OFFICE VISITS AND OTHER SERVICES TO YOUR INSURANCE IF YOU WISH.

Question 19 of 21

ON A SCALE OF 1-10 (1= I DON'T WANT TO CHANGE ANYTHING, 10=IAM WILLING TO CHANGE ANYTHING AN EVERYTHING IF NEEDED), HOW COMMITTED ARE YOU TO SOLVING THIS PROBLEM ONCE AND FOR ALL?

Question 20 of 21

IS THERE ANYONE ELSE INVOLVED IN YOUR HEALTH AND FINANCIAL DECISION MAKING PROCESS THAT NEEDS TO BE PRESENT ON OUR UPCOMING CALL?  (SPOUSE, FAMILY MEMBER, ETC.)

A

NOPE! JUST ME.

B

YES, I HAVE ANOTHER FAMILY MEMBER I NEED TO CONSULT WITH BEFORE MAKING THIS DECISION.

Question 21 of 21

IF YOU COULD ONLY EAT ONE THING FOR THE REST OF YOUR LIFE, WHAT WOULD IT BE? (THIS IS JUST FOR FUN!)

Confirm and Submit