Site icon The Forbidden Doctor

Existing Patient Survey

Excellent! You’ve Made a Great Choice!
Now, Take The Symptom Survey

Give us a picture of your current health and we will build you a customized nutritional protocol with a 30 minute phone consultation. There is no obligation to buy anything. Get back to doing what you want to do! Let us handle the details.

Here’s How It Works:

1. Take the Symptom Survey below

2. Leave the email address intact, so we know it’s you from your existing account. (if no address is present, please type the address you used during your purchase.)

3. Answer all questions to help us understand what we know about your situation. Your personalized protocol won’t be ready right away. A nutritional counselor will analyze your confidential survey information and create a custom nutritional protocol – just for you. It can take a few business days.

Let’s get started!

PLEASE NOTE: Every survey is protected under HIPAA and is kept completely confidential. Your secure results will be evaluated by Dr. Jack or Mary, or one of our well-qualified nutritional consultants and shared only with you, as we set up your secure account online.

Step 1 of 8 - Yes! You are taking the survey! First some basic information...

  • MM slash DD slash YYYY
  • Please indicate which symptoms or issues you are experiencing below:
    Never symptoms - Never experience symptomsMild symptoms - Once or twice in the last 6 monthsModerate symptoms - Once or twice in the last monthSevere symptoms - Chronic, once, twice, or more in the last week
  • Group 1
  • Group 2
  • Same deal here. Please provide scoring values for all that apply:
    Never symptoms - Never experience symptomsMild symptoms - Once or twice in the last 6 monthsModerate symptoms - Once or twice in the last monthSevere symptoms - Chronic, once, twice, or more in the last week
  • Group 3
  • Group 4
  • Same deal here. Please provide scoring values for all that apply:
    Never symptoms - Never experience symptomsMild symptoms - Once or twice in the last 6 monthsModerate symptoms - Once or twice in the last monthSevere symptoms - Chronic, once, twice, or more in the last week
  • Group 5
  • Group 6
  • Same deal here. Please provide scoring values for all that apply:
    Never symptoms - Never experience symptomsMild symptoms - Once or twice in the last 6 monthsModerate symptoms - Once or twice in the last monthSevere symptoms - Chronic, once, twice, or more in the last week
  • Group 7a
  • Group 7b
  • Group 7c
  • Same deal here. Please provide scoring values for all that apply:
    Never symptoms - Never experience symptomsMild symptoms - Once or twice in the last 6 monthsModerate symptoms - Once or twice in the last monthSevere symptoms - Chronic, once, twice, or more in the last week
  • Group 7d
  • Group 7e
  • Group 7f
  • Same deal here. Please provide scoring values for all that apply:
    Never symptoms - Never experience symptomsMild symptoms - Once or twice in the last 6 monthsModerate symptoms - Once or twice in the last monthSevere symptoms - Chronic, once, twice, or more in the last week
  • Group 8
  • Same deal here. Please provide scoring values for all that apply:
    Never symptoms - Never experience symptomsMild symptoms - Once or twice in the last 6 monthsModerate symptoms - Once or twice in the last monthSevere symptoms - Chronic, once, twice, or more in the last week
  • Final Questions
  • This field is for validation purposes and should be left unchanged.
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