Thank You for Filling Out This Questionnaire
from the practice of Dr. Hale, AP, owner of iPlanet Health
This is a complimentary service. You are under no obligation
Please call us at 561-337-9435 if you have questions

Question Title

* 1. How physically healthy are you?

Extremely healthy

Very healthy

Moderately healthy

Slightly healthy

Not at all healthy

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* 2. Do you take nutritional supplements?

Yes

Sometimes

If you like, you can list some of the supplements you are presently taking

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* 3. Do you take other medications?

Yes

Sometimes

If you like, you can list some of the medications you are presently taking

Question Title

* 4. Are you presently under a doctor or alternative practitioner's care?

Yes

It has been a while

You may provide the name of your doctor (this is optional). This information would be helpful for Dr. Hale, AP to know

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* 5. How important is exercise to you?

Extremely important

Very important

Moderately important

Slightly important

Not at all important

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* 6. What do you most often do for exercise?

Lift weights

Walk

Run

Hike

Swim

Dance

Aerobics

Pilates

Play a team sport

Other (please specify)

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* 7. Would you like to comment on your diet? (This question is optional)

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* 8.
Would you like to provide info on your wellness goals in order that Dr. Hale, AP may better assist you?

(This question is optional and can also be addressed via a complimentary phone consultation, if you prefer).

Providing some info here is always very helpful in helping Dr. Hale to better help you.

Also please note - We provide complementary wellness support protocols for different conditions
If you would like for Dr. Hale to provide you with a suggested protocol - please indicate

Question Title

* 9.
In order for us to complete your Wellness Client status, Please provide some basic contact info.
This field is required.

Please Note:

You are entitled as a Wellness Client to a complimentary 10 minute phone consultation.

Give us a call and if Dr. Hale, AP is available he would be happy to talk with you
(if he is busy then you can schedule a call back time)
Our office number is 561-337-9435.

Our business hours are 10-5 M-F EST - After hrs please leave a message.

Name *

Email Address

Phone

By filling out this questionnaire - I am authorizing Dr. Hale, AP to be part of my advisory Well-Care team. I understand that I can contact Dr. Hale, AP via phone or email when I need product or general wellness advice. Please provide your consent by typing your initials in this box -> *