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)

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)

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?

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.

About Us

If you’re ready to change your life so you can start feeling better, you’re in the right place. At Pure Vitality, our goal is to uncover the obstacles that are keeping you stuck and to give you the tools you need to improve your health and your life- for good!

Connect

Address: 3614 Hwy 5, Douglasville Ga 30135

Phone: 770-920-PURE (7873)

EMAIL: getpurevitality@gmail.com

Office hours: Mon-Fri: 10a-5:30 | Sat: 10a-2p