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: *

What has improved since your last visit? Or what symptoms are you no longer experiencing?

List your current symptoms you are experiencing:

What has stayed the same since your last visit?

What has gotten worse since your last visit?

Where you able to follow your protocol? Any challenges with taking your supplements?

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?

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 you having one or more bowel movements each day?

Yes

No

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