Readiness Assessment Form

* Name:
* Email:
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Rate on a scale of 5 (very willing) to 1 (not willing) and then answer why you selected the rating.
In order to improve your health, how willing are you to:
* 1. Make a financial investment
* 1. Why?
* 2. Take responsibility for your health
* 2. Why?
* 3. Prioritize putting your health first
* 3. Why?
* 4. Commit to the program and be held accountable
* 4. Why?
* 5. Change your lifestyle (e.g. work demands, sleep habits)
* 5. Why?
* 6. Eliminate alcohol
* 6. Why?
* 7. Significantly modify your diet
* 7. Why?
* 8. Keep a record of everything you eat each day
* 8. Why?
* 9. Take whole food supplements 4-5 times a day
* 9. Why?
* 10. Strictly follow supplement protocol and be monitored
* 10. Why?
* 11. Engage in regular exercise program
* 11. Why?
* 12. Practice relaxation techniques to manage stress
* 12. Why?
* 13. Eliminate common distractions (media, trends, Dr. Google)
* 13. Why?
* 14. Leverage resources provided to learn more about nutrition
* 14. Why?
* 15. Have periodic lab tests to assess progress
* 15. Why?
* 16. Have additional diagnostic testing as needed
* 16. Why?
* 17. Follow physician guidance & communicate regularly
* 17. Why?
* 18. Allow for the time it takes to be successful
* 18. Why?
* 19. Be honest with yourself and the doctor
* 19. Why?
* 20. Fully invest in the program because YOU want it
* 20. Why?
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