Dr. Infantino's

Assessment Application

Before we meet I'd like to get a very clear picture of your current struggles and long term health goals. Please take your time and fill out the assessment honestly and completely. Your answers will help me truly understand if my approach is the best fit for you.

Thank you, Dr. I

Today's Date

First Name *

Last Name *

Phone *

Best eMail *

Address *

City *

State *

Postal code *

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

Age *

Current Weight *

Ideal Weight *

Last time at your ideal weight: *

Height *

My current health goals are ... *

Please be as detailed as possible.

Why are these goals important to you now? Please explain. *

What is it about my approach explained in the video that resonated with you? *

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

If your commitment level is 9 or below, why?

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? *

Are you currently on prescription medication? *

Yes

If yes, for which conditions?

Digestive issues

High blood sugar / diabetes

High blood pressure

High cholesterol

Anxiety / depression

Thyroid

Anti-inflammatories

HRT

Other

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 $150-$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

Disclaimer: In our Assessment Form, we ask for some limited health history from you. We ask these questions because health coaching guidance can be more useful if we know the overall context. In addition:

We may want to encourage and advise you to consult with your medical professionals for any disease conditions.

We may in the future be able to refer you to various networks of healthcare professionals, and therefore it will be easier if we have a more complete record of your overall wellness.

Having said that, as noted below, we are only providing coaching guidance— focusing on lifestyle, habits, and goals—and never giving you medical or psychological advice about the underlying condition.