DETOX QUESTIONNAIRE

I’m excited for you to begin on this health journey!

First, I need a bit of information from you, then we’ll schedule our coaching call(s) to ensure you have all the support you need.

Plan for just 5 minutes to complete this form. All data is kept confidential.

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

Height

Weight

Gender

Occupation

How many days is your detox?

Preferred shake flavor?

Mailing Address (for your kit)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What's your reason for doing this detox? What outcome are you anticipating?

Have you completed a Functional Medicine Detox in the past/what have you tried for detox in the past?

Additional questions or concerns you'd like to address during our call?

List past Medical and Surgical History:

What medications are you taking now? (prescription)

I have read and understand everything on this page. I acknowledge Susan Kostyk and her associates are natural health practitioners and do not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Susan Kostyk, her lab partners, her independent representatives, associates and affiliates from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their natural health services. All information provided is for health education purposes only and is not intended to diagnose, treat, cure or prevent any disease.

Yes, I understand

DETOX QUESTIONNAIRE

NEED PERSONALIZED CARE?