Follow-Up Interview – LSA | Revitalize Health

REVIEW INITIAL INTERVIEW

Provider's Name:

Date

Confirm Practice information:

How do practice members refer to the provider
Primary contact email for our staff
Primary contact phone number for our staff

Practice Information notes:

Confirm Coaching Option:

Revitalize Health Coaching
Coaching provided by them

Confirm these coaching details:

Process for scheduling office visits
Process for receiving lab requisitions
Discussion about Food Sensitivity Tests timing
Option to recommend Keto

Confirm these coaching details:

Names of practice's coaches
Phone number for practice member program-related questions
Email for practice member program-related questions
Method for practice members to schedule their coaching calls

Additional Coaching Notes

Review Dietary Transition Options:

Revitalize Health transitions
Keto transitions
AIP transitions
Non-Protocol Version
Custom Dietary Transitions

Review the submitted custom dietary transitions

Confirm dietary transitions timing
Confirm receipt of specific days and eliminations

Review Post-Detox food reintroductions:

Using Revitalize Health
New reintroductions submitted

Additional transitions notes:

After reviewing the dietary transitions and confirming timing, please make any other necessary notes for preparing the scripts and filming.

Review Supplement Protocol Options Here

Confirm Supplement Protocol Option:

Xymogen
Ortho Molecular
Fullscript
Ortho + Fullscript (Mixed)
Plant-Based Ortho Molecular
Non-Protocol
Custom Supplement Protocol

Do you use a detox "shake" for your detox, or is it some other form of supplement?

Yes
No

Details about the detox shake or other detox supplement:

Confirm Detox length:

14 days (no change needed)
Custom length

Timing Option chosen:

7 Day Detox
21 Day Detox
28 Day Detox
Other

Review protocol provided to confirm "fit" into our curriculum. If other length is listed, please list length in "Additional Supplement notes" section.

Additional Supplement Notes

After reviewing the protocol, confirm program timing and make any necessary notes for preparing the scripts and filming.

Confirm filming dates for Pro-level

Confirmed
Undecided
Not Pro-level

Review of Implementation Guide

Reviewed:

Review that they received the portal user guide and know how to use it

Confirm portal user guide receipt

Additional Notes for Development Staff

Follow-Up Interview - ALL

REVIEW INITIAL INTERVIEW