Initial Progress Survey Name* First Last Date MM slash DD slash YYYY Phone*Email* At which Revitalize Health location are you a patient?* Sugar Land The Woodlands What problem(s) originally brought you to see us?*How would you rate your progress thus far?*Same as beforeOKFairGoodSignificantExcellentHow would you rate the staff's response to your concerns?*PoorFairGoodSignificantExcellentHow would you rate the doctor's response to your concerns?*PoorFairGoodSignificantExcellentAre you up to date on reading your curriculum binder?* Yes No If no, please explain why:Have you implemented the "Reclaim 24" exercise program?* Yes No If no, please explain why:Have you completed the 14 Day Detox protocol?* Yes No If no, please explain why:Have you kept on schedule with the program?* Yes No If no, please explain why:Rate your overall participation level up to this point in the Revitalize Health Program*(1 is lowest, 10 is highest)Please enter a number from 1 to 10.Please share some of the results you have achieved thus far on the program:*What improvements to the program would you suggest at this point?* Did you know that we help patients who suffer from the following conditions? Autoimmune Disease Fibromyalgia Diabetes Metabolic Syndrome Thyroid Conditions Digestive Disorders Chronic Fatigue Weight / Obesity Cardiovascular Health ....and more! If you have experienced positive changes in your health because of the Revitalize Health program and wish to see others around you gain the same benefits, please consider referring a family member, friend, co-worker, or neighbor. Would you like someone from our staff to reach out to you about scheduling an initial consultation for someone in your life?Please contact me about an initial consult for someone I know: Yes No
