Medical coaching questionaire – nextgenpharm

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Medical coaching questionaire

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- Step 1 of 2

Please help us understand your struggles and how you’d like our medical coaches, Dr. Sarah and Dr. Syria, to help. We will contact you to arrange a convenient time to discuss your goals for coaching.

Consultations cost £80 for a 15 minute session.

Date of birth *

Birth gender *

Female
Male

What challenges do you want to address? *

Achieving a healthy weight
Hormonal imbalance
Difficulty sleeping
Hair loss
Libido
Something else

Please provide more details *

How would you rate your physical health? *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

What is your current exercise routine, if any? *

How would you rate your nutrition and eating habits? *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Do you experience stress, anxiety, or depression? If so, how often? *

All the time
Often
Occasionally
Rarely
Never

Are there any habits you feel are holding you back? *

What does success look like for you in this coaching relationship? *

Name *

First

Last

Date of birth *

Name challenges exercise

Email *

Phone *

Do you agree and consent to the following?

I am at least 18 years old and live in the UK.
I have the capacity to make decisions about my own healthcare
I confirm that I have provided all answers and that they are truthful.
I agree to your terms and conditions, privacy and acceptable use policies.
I am aware I will be subject to a soft check to validate my identity using LexisNexis.

Consent *

I agree to the statements and give my consent for any coaching or treatment provided.

7 Mulberry Way
South Woodford
E18 1EB

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Conditions

Weight loss
Vitamins and Supplements
HRT
Hair loss
Erectile dysfunction
All conditions

Weight loss
Vitamins and Supplements
HRT
Hair loss
Erectile dysfunction
All conditions

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Pharmacy owner APC Labs Ltd, GPhC: 9012301.
Prescribing services APC Labs Ltd, Unit 2 Hamble Court Business Park, Hamble Lane, Southampton, SO31 4QL. Dispensing services APC Labs Ltd, GPhC: 9012301. Compounding Services APC Labs Ltd.

Superintendent Pharmacist: Mr. Shazlee Ahsan (GPhC: 2046605)