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Prospective Patient Application~Dr. Terra Winston N.D

Welcome! My passion is helping high performers get into the best health EVER so they can work harder, faster, and smarter without burning out! 

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 23

NAME: (FIRST, LAST)

Question 2 of 23

EMAIL ADDRESS:

Question 3 of 23

FULL ADDRESS: CITY, STATE, ZIP 

Question 4 of 23

IN WHAT STATE DO YOU CURRENTLY RESIDE?

Question 5 of 23

BEST CONTACT PHONE

Question 6 of 23

AGE

Question 7 of 23

HOW DID YOU FIND DR. TERRA?

Question 8 of 23

WHAT ARE YOU LOOKING FOR HELP WITH?

(Select all that apply)
A

Joint pain or injuries

B

Autoimmune disease

C

Gut health

D

Lyme Disease

E

Aesthetics

F

Anti-aging

G

Hormonal issues

H

Mold Illness

I

Weight loss

J

Other, Please describe below

Question 9 of 23

Other description: Please enter N/A if not applicable.

Question 10 of 23

BRIEFLY EXPLAIN ABOUT YOUR CURRENT HEALTH STRUGGLES

Question 11 of 23

DO YOU CURRENTLY TAKE PHARMACEUTICAL MEDICATIONS?

Question 12 of 23

HOW LONG HAVE YOU BEEN EXPERIENCING SYMPTOMS?

A

<6 MONTHS

B

6 -12 MONTHS

C

1 - 3 YEARS

D

3+ YEARS

Question 13 of 23

HAVE YOU WORKED WITH ANOTHER PRACTITIONER FOR THIS ISSUE?

A

YES

B

NO

Question 14 of 23

IF YES, PLEASE DESCRIBE. Please enter N/A if not applicable.

Question 15 of 23

IN AN IDEAL WORLD, WHAT WOULD YOU LIKE YOUR HEALTH TO LOOK LIKE IN 6 MONTHS? TRY TO BE SPECIFIC. (I.E., I WILL HAVE ENERGY, I WILL NO LONGER HAVE PAIN IN MY GUT, I WILL BE ABLE TO SLEEP THROUGH THE NIGHT.)

Question 16 of 23

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 23

WHAT DO YOU WANT MOST FROM DR. TERRA? (GENERAL HEALTH ADVISE, SOMEONE TO HOLD ME ACCOUNTABLE IN UNDERTAKING MY LIFESTYLE CHANGES, SOMEONE TO MANAGE LABS AND MEDICATIONS, ETC.)

Question 18 of 23

DO YOU FOLLOW AN EXERCISE ROUTINE? IF SO, PLEASE DESCRIBE. IF NO, ARE YOU WILLING TO BEGIN ONE THAT IS TAILORED TO YOU AND YOUR CURRENT ABILITIES?

Question 19 of 23

YOUR HEALTH IS AN INVESTMENT! ESTABLISHING A HEALTHY FOUNDATION NOW COULD SAVE YOU THOUSANDS IN MEDICAL BILLS 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.

 

HOW MUCH ARE YOU WILLING TO INVEST IN YOUR HEALTH PER MONTH? 

A

$500-$1,000

B

I AM WILLING TO INVEST WHATEVER IS NEEDED TO ACHIEVE MY HEALTH GOALS.

Question 20 of 23

IF YOU ARE A VETERAN, A STUDENT, OR ARE FACING FINANCIAL CHALLENGES AND YOU WOULD LIKE INFORMATION ON DR. WINSTON'S 501-c3 NON-PROFIT PROGRAM, PLEASE CHECK THE BOX.

 

NOTE: PROOF OF FINANCIAL HARDSHIP WILL BE REQUIRES AS SPACE IS LIMITED. 

A

YES, I AM INTERESTED IN THE NON-PROFIT OPTION.

B

NO THANK YOU

Question 21 of 23

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 IMPROVING YOUR HEALTH RIGHT NOW?

Question 22 of 23

IS THERE ANYONE ELSE INVOLVED IN YOUR HEALTH AND FINANCIAL DECISION MAKING PROCESS? (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 23 of 23

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