HOPE & WELLNESS APPLICATION

Please fill out your information below and Melissa will be happy to see how she can best serve you.

Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State/Province

Zip/Postal

Country

Cell Phone Number *

What is your best email address? *

What are your top 3 health problems or concerns? *

When was the last time you felt well? *

Did something trigger your change in health? *

What makes you feel worse? *

What makes you feel better? *

What are your health goals? *

What are your top motivating factors in reaching your health goals? *

Are you on a special diet? *

Yes
No

List any medications and/or supplements you are currently taking. *

Who else have you worked with? *

Functional Medicine Practitioner
Medical Doctor
Medical Specialist
Naturopathic Doctor
Osteopathic Doctor
Traditional Chinese Medicine
Nutritionist
Personal Trainer
Chiropractor
Personal Development Coach
Other

What functional lab testing have you had done? *

Functional Stool Testing
Organic Acids Testings
Genetic or Genomic Testing
Hormone Testing
Heavy Metal Testing
None
Other

Considering your past treatments, what would you like to improve or do differently moving forward? *

Are you willing to do what's necessary to reclaim your health? (This may include, dietary modifications, functional lab testing, lifestyle and environmental modifications) *

Yes
No

What else would you like Melissa to know so she can best serve you?

Health Coaching Policy

I AGREE

Electronic Signature *

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The material on the Website is provided for general informational purposes only and is not intended as medical advice, or as a substitute for the medical advice of a physician. The statements made on this Website have not been evaluated by the Food and Drug Administration or the State of Georgia and are not intended to diagnose, treat, cure or prevent any disease. Likewise, the information provided by Melissa Nohr is for informational purposes only, is not intended to diagnose, treat, cure or prevent any disease, and has not been evaluated by the Food and Drug Administration or the State of Georgia.