Client Questionnaire

Truer Path - functional nutrition alliance

Thank you for taking the time to fill out this questionnaire.

This form will automatically create a new user account in the Truer Path Client Domain system. If you already have a Client Domain account, please do not use this online version of the form. Use the fillable form in your account's personal documents instead.
Client Information
Name:
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Address:
City:
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State:
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Zip Code:
Country:
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Phone (day):
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Phone (cell):
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Phone (night):
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Email:
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Are you filling this survey out for yourself or on behalf of another person?
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Questionnaire
How did you find me?
Referred By:
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What are your main goals for seeking nutrition counseling?
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Do you have any known health or medical conditions or diagnosis that I should know about in helping you to find the best care?
If yes, please explain.
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What have you tried so far to address your goals?
(Diets, testing, modalities, etc.)
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Which of the following items are currently in your diet in any amount?
(select all that appply)




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What percentage of your meals are currently home cooked?



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Please let us know anything else about you, your goals for nutrition counseling or your health aspirations.
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We are committed to working with individuals who are dedicated to their health and ready to receive support on their individualized journey to health and healing. We're uniquely poised to uncover and unlock the evolving protocol that will deliver the results you've been seeking.
In two or three sentences, tell us something about yourself and/or your health history that will help us get to know you before we take any further steps to dig more deeply into the details of your concerns.
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When you click Save, a Truer Path account will be created for you, and your Questionnaire will be filed in the system. This will take 5 to 20 seconds.