Follow Up appointment Follow Up Form Thank you for filling out this form before your next appointment. Please let us know what’s changed since your last visit so we can serve you better! Follow Up Form Name: * Date: * Have you emailed a picture of your Program Tracker to your practitioner? (Send to getpurevitality@gmail.com) Yes No What victories have you had this month? Were you able to follow your protocol? Any challenges with anything? What did you learn from watching the videos in the Total Wellness Program portal? If you have not seen your practitioner in the past 6 months, please write down your top 3 current health concerns: (Omit this question if you are currently working with us) Please rate your current stress level: None to Low Low Moderate Moderate to High High Very High If stress level is high or very high, what is the source of your stress? How many hours of sleep are you currently getting on average? 1-3 hours 4-5 hours 6-7 hours 8 hours 9-10 hours Are you having one or more bowel movements each day? Yes No How is your current diet? List what you are currently eating for breakfast: List what you are currently eating for lunch: List any snacks you are having: List what you are currently eating for dinnner: Are there any questions or concerns you have for your practitioner? Please put them below. reCAPTCHA Submit If you are human, leave this field blank.