Name* First Last Please take a moment to complete this short questionnaire. Once submitted, You will receive an email shortly with our initial recommendations. Be sure to check your email and spam. Email* We would love to talk with you! First tell us what are your Top 3 or 4 Health Concerns?*How Soon are you looking to work with our office.*Have you been diagnosed with an Autoimmune Disease ?* Yes No Not Sure- Need Help in determining this Do you feel you have had the proper testing to treat your condition properly?* Yes No Not Sure- Need Help in determining this Do you feel you need more help with diet? Or are you looking to dig deeper into the root cause of your health problems with Functional lab testing.*When was the last time you had blood work?* Within the last 3 months Within the last 6 months It has been over 12 months How would you rate the complexity of your case- Mild, Moderate, Severe ?* Mild Moderate Severe What have you done up to this point in an effort to regain your health ?*Final Question- Unfortunately, Insurance covers only the most basic testing. Functional lab testing is not covered. We will try to do everything we can stay within your financial budget. How would you describe your Health Budget?*Less than $500$500-$1,000$1,000-$2,000$2,000-$4,000$6,000-$7,000Your Financial budget determines what labs we use, the kinds of testing we would recommend, and how thorough of a workup than can be performed.Optional MessageAfter Dr. Hagmeyer reviews your questionnaire you will be contacted via email with your next steps.