Champion for Life Questionnaire Start Healing Today 01. Name (First & Last) 02. Address (City, State, Zip) 03. Phone Number 04. Email Address 05. Are you inquiring about yourself, a child, or family member? (Short Answer) 06. How long have symptoms been present? (Short Answer) 07. Have you, or a family member, been diagnosed with Lyme Disease by a physician? Yes No If yes, how long ago, and when did symptoms begin? 08. Are you working with a Lyme Disease literate doctor? Yes No If yes, is he willing to work with someone who’s healed themselves and others? 09. What are your current primary symptoms or challenges related to Lyme disease, and which ones are most important for you to address? 10. What wellness approaches or treatments have you tried so far, and how effective have they been for you? 11. Do you have specific short-term or long-term goals for your health and well-being, such as improving energy levels, reducing inflammation, or enhancing mental clarity? 12. How do you currently manage stress, sleep, and diet, and are there areas you’d like to improve? 13. Are there any physical activities or hobbies you’d like to resume or continue, and what challenges, if any, are preventing you from doing so? 14. Are you interested in a support group or support system for your healing? Yes No If yes, please describe what you would be looking for. (Short answer) Submit Here
