Gut, Liver and Cell Toxicity

Assessment Form

Thank you for investing in the next few minutes in you! Your thoughtful answers will help Dr. Infantino prepare for your meeting and help determine if his unique approach can help you hit your health goals once and for all :-)

Today's Date: *

First Name *

Last Name *

Phone *

Email *

Address *

City *

State *

Postal code *

Age *

Referral from a friend?

Your Gender *

Male

Female

Whom or what (TV, online, etc.) may we thank for referring you? *

Facebook

Instagram

TikTok

Google Search

Referral

Other

Current Weight *

Ideal Weight *

Last time at your ideal weight: *

My current health goals are ... *

On a 1 to 10 scale, how committed are you to achieving your goals? *

Why are these goals important to you now? *

Is your spouse or significant other supportive of your health goals? *

Yes

N/A

What is your energy level on a scale of 1 to 10? *

On Rx Medicine? If so for what? (not the brand, just what it's for) *

Mood swings? Irritable or easily angered? *

Yes

Suffer from brain fog or memory issues lately? *

Yes

Have you had sinus / ear issues? *

Yes

Have less motivation/zest for life? *

Yes

Digestion / Gut and Liver Assessment

Do you experience? Choose any that apply. *

Bloating

Reflux

Constipation

Diarrhea

Indigestion

None of the above

Which foods make any of the symptoms worse?

Do you crave carbs- sugar, beer, wine or bread etc? *

Yes

Have you ever had candida / yeast concerns? *

Yes

Do you sleep well? *

Yes

Ever take antibiotics? *

Yes

Do you suffer from inflammation? (aches and pains, stiff joints, trouble concentrating, etc.) *

Yes

Stress Assessment / Adrenal Function

Are you happy with current profession? *

Yes

Are you comfortable financially? *

Yes

Are you satisfied with your life's direction? *

Yes

Do you recover less easily from exercise? (worn out for a day or two) *

Yes

Do you find yourself more anxious or depressed lately? *

Yes

If Dr. Infantino can help, he’ll design and recommend a specific short term plan. If he created a plan which would be the most important to you? *

EFFECTIVENESS "Results that last are my top priority."

TIME "I want my results quickly."

SERVICE "I will need extra support along the way."

AFFORDABILITY "Cost is a major concern."

If Dr. Infantino can help are you currently in a position to invest in your health if doing so would correct the root cause of health challenges so you could enjoy the results for a lifetime? To give you an idea, when spread over time programs can range anywhere $60-$350 per month. *

Yes

Possibly w/ Financing

We completely understand sometimes the timing isn’t quite right to invest any amount in our health. Since the purpose of this consultation is for Dr. Infantino to determine if he can create a program for you that would require some investment, we could refund your $27 if you’d like. Or......................We would like to give you a $47 ($20 FREE:) credit in our online store to pick any supplement along with a list of "Foods to Eat" and "Foods to Avoid" to decrease inflammation and heal the gut and liver from this program.

No - Keep the $27 and send me a $47 credit to DrInfantino.store.

Yes- Please refund my $27