Health Questionnaire

Please answer the following questions so that I can prepare for our call.

Please note: No medical advice will be given on this call.

First Name

Last Name

Your Age: *

Email *

Relationship status: *

Single

Married

In a relationship

Widowed

What are the health concerns causing you suffering right now? Please include official diagnoses and other concerns without an official diagnosis. *

How are your migraines affecting your daily life? *

How many migraine headaches do you experience per week? *

Less than 1 per week

1 per week

2-4 per week

5 or more per week

What lifestyle changes or natural therapies have you tried in the past? *

Chiropractic

Acupuncture

Naturopath or Naturopathic Doctor

Functional Medicine

Migraine Diets and/or specific diets (such as IEP, GAPS, Paleo, etc)

Magnesium/CoQ10/B Vitamins

Other(s)

What prescription and over the counter medications are you taking now? How are effective are they at treating your symptoms? Please include all prescription medications, even if not related to migraines. *

People who have watched my free training on the 5 Steps to Healing Migraines Naturally get more out of our call. Have you watched this training within the past month? *

Yes, I have watched the 5 Steps to Healing Migraines Naturally within the past month

I've watched the training but it has been a while...

No, I have not watched the training yet

How would your life change if your migraines improved *

Select the statement that best matches your level of commitment right now: *

I am absolutely ready to do what I need to do to start feeling better today

I would like to feel better but I'm not sure if I'm ready to do what I need to do

I'm not in a position to do anything different right now, I'm just booking the call because I'm curious about your approach.

You are welcome to bring a support person to this call (for example: spouse, partner, parent, friend, etc): *

My spouse/partner/support person will attend the call.

My spouse/partner/support person is very interested to hear how this call goes, but will not attend the call.

My spouse/partner/support person is not interested in attending the call and not that interested in hearing how the call goes.

My spouse/partner/support person is not aware that I booked the call.

How did you hear about Dr. Leslie? *

Facebook Group

Google

Podcast

Referral

Other

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