Patient Questionnaire

Please fill out the following questionnaire prior to your phone consultation with either Dr. Steve King, Dr. Mark King, Dr. Donna Moloney, Dr. Eric Eiselt or Dr. Jason Placeway.

Name:

Phone Number:

Email:

Address:



Please describe in detail your primary concern:


Please describe in detail what you want out of this process:


Are you willing to participate in an exercise program?
Yes No
Are you willing to make serious dietary changes?
Yes No
Are you willing to take supplements?
Yes No