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Readiness Assessment Form
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required information
Rate on a scale of 5 (very willing) to 1 (not willing) and then answer why you selected the rating.
In order to improve your health, how willing are you to:
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1. Make a financial investment
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1. Why?
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2. Take responsibility for your health
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2. Why?
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3. Prioritize putting your health first
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3. Why?
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4. Commit to the program and be held accountable
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4. Why?
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5. Change your lifestyle (e.g. work demands, sleep habits)
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6. Eliminate alcohol
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6. Why?
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7. Significantly modify your diet
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7. Why?
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8. Keep a record of everything you eat each day
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8. Why?
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9. Take whole food supplements 4-5 times a day
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9. Why?
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10. Strictly follow supplement protocol and be monitored
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10. Why?
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11. Engage in regular exercise program
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11. Why?
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12. Practice relaxation techniques to manage stress
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12. Why?
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13. Eliminate common distractions (media, trends, Dr. Google)
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14. Leverage resources provided to learn more about nutrition
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15. Have periodic lab tests to assess progress
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15. Why?
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16. Have additional diagnostic testing as needed
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16. Why?
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17. Follow physician guidance & communicate regularly
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17. Why?
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18. Allow for the time it takes to be successful
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18. Why?
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19. Be honest with yourself and the doctor
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19. Why?
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20. Fully invest in the program because YOU want it
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20. Why?
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