Questionnaire for the touch base complementary consultation.

1. Name: 2. Age: 3. Gender: 4. Phone number: 5. What is the name of your doctor? 6. Diagnosis: 7. Current pharmaceuticals: 8. Current supplements: 9. What are your health concerns? 10. What are your health goals? 11. What is currently preventing you from reaching your health goals? 12. Realistically on a scale of 1 to 10 how motivated are you in making changes to increase your chances of reaching your health goal? A rating of 1 is no motivation and 10 is you will do pretty well anything and everything and this will likely include giving up less than optimal lifestyle habits (i.e. bad habits). 13. If you are taking pharmaceuticals to manage a chronic medical condition are you open to using fewer drugs if possible? 14. If your answer is "Yes" to question 13, are you open to transferring your RX file to us so we can help you explore the possibility of reducing your medications? Please give the name of the pharmacy and their phone number.
Please see our Medication Reduction Services page for more information about this unique and innovative service our pharmacy provides. 15. Is there anything specific you would like us to help you with?

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The information within this website represents the personal opinion of the author, pharmacist Peter Lee, and is intended for informational purposes only. It is not meant to diagnose or treat any specific medical condition or symptom. Please seek a qualified healthcare practitioner for an individualized treatment plan for your own personal health situation.

Questionnaire

Questionnaire for the touch base complementary consultation.

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