Patient Motivation Profile - Naturopath Solutions

Full Name

Date

E-mail address

1. List your top three priorities in life.

2. What three health goals can we help you achieve? How long do you think it might take you to achieve these health goals?

3. Has anything stopped you from achieving your health goals in the past? Examples of things that could stop you achieving your health goals include not enough time, lack of support or not enough money. Do you think any of these may stop you from achieving your current health goals?

4. What has helped motivate and inspire you to make significant life changes in the past and/or what could help motivate and inspire you to make changes now? Examples may be your family or friends, a ‘health scare’ or a special event such as a wedding or birth of a child. Please comment on how/why these motivate you.

5. Please rate the following below on a scale of 1 (poor) to 5 (excellent). Please comment on why you have given this rating.

5a. General health and wellbeing

5a. Comment

5b. Overall quality of your diet

5b. Comment

5c. Sense of calm and relaxation

5c. Comment

5d. Quality and quantity of sleep

5d. Comment

5e. Exercise and general activity levels

5e. Comment

6. To improve your health and wellbeing, you may be asked to make some changes to your diet and/or lifestyle. If requested air jordan 1 high skyline by your Practitioner, how willing would you be to do the following? Please rate on a scale of 1 (not willing at all) to 5 (extremely willing). Please comment on why you have given this rating.

6a. Significantly modify your diet

6a. Comment

6b. Keep a record of everything you eat each day

6b. Comment

6c. Engage in regular exercise/activity

6c. Comment

6d. Alter your work patterns

6d. Comment

6e. Practice relaxation technique(s) on a regular basis

6e. Comment

6f. Modify your sleep habits

6f. Comment

6g. Take nutritional and/or herbal supplements each day

6g. Comment

6h. Have periodic consultations to assess your progress

6h. Comment

7. With our guidance and support, how confident are you in your ability to follow through on the above activities? Please rate on a scale of 1 (not confident at all) to 5 (extremely confident). CONFIDENCE is:

7. Comment

8. How supportive do you think your family and friends will be in helping you implement the above changes? Please rate on a scale of 1 (not supportive at all) to 5 (extremely supportive). SUPPORT is

8. Comment