SurveyMonkey Powered Online Survey

Welcome to The Moday Center! We look forward to learning more about you. Please fill out the survey so we can help you reach your health goals.

We will review your answers and get back to you via email, typically within one business day, with information on your next steps to become a patient.

Question Title

* What are your primary health concerns?

Mood / depression / anxiety

Lack of energy / fatigue

Digestive issues

Brain fog / cognitive improvement

Adrenal hormone imbalances

Food sensitivities

Perimenopause / menopause

Insulin resistance / prediabetes / diabetes

Lipid (cholesterol) imbalances

Autoimmune disease

Fertility / infertility

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* Please briefly describe your primary reason for coming to see us and be as specific as possible:

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* Where are you in the journey of addressing your health concern stated above?

Readiness Assessment

In order to improve your health we want to know how willing you are to do the work? Please rate on a scale of 1 (not willing) to 5 (extremely willing).

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* Modify diet based on lab testing

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* Take nutritional supplements based on lab results

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* Keep a record of everything you eat certain days

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* Modify your lifestyle (e.g., work demands, sleep habits)

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* Practice a stress-management technique

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* Engage in regular exercise

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* How coachable are you?

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* How did you hear about us? Please be as specific as possible.

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* Were you referred to us?

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* If 'YES' by whom?

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* What program are you interested in?

Comprehensive Medical Program

Foundational Medical Package

Nutrition First Program

Bright & Balanced Program

Jumpstart Program

Better Brain Program

Unsure

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* Please provide your contact information:

Name

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* What is your date of birth?

Please enter your date of birth:

Date

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* What is your gender at birth?

Female

Male

Prefer not to answer

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* Optional: What is your gender identity?

Woman

Man

Genderqueer or non-binary

Agender

Other

Not specified above, please specify

Question Title

* What are your primary health concerns?

Question Title

* Please briefly describe your primary reason for coming to see us and be as specific as possible:

Question Title

* Where are you in the journey of addressing your health concern stated above?

Question Title

* Modify diet based on lab testing

Question Title

* Take nutritional supplements based on lab results

Question Title

* Keep a record of everything you eat certain days

Question Title

* Modify your lifestyle (e.g., work demands, sleep habits)

Question Title

* Practice a stress-management technique

Question Title

* Engage in regular exercise

Question Title

* How coachable are you?

Question Title

* How did you hear about us? Please be as specific as possible.

Question Title

* Were you referred to us?

Question Title

* If 'YES' by whom?

Question Title

* What program are you interested in?

Question Title

* Please provide your contact information:

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* What is your date of birth?

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* What is your gender at birth?

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* Optional: What is your gender identity?

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* Do you have any questions for us? Make sure to check out our FAQ's on the website.