Thank you for your interest in my practice.

Please answer the following questions with 100% honesty so that I can learn more about you. Once I’ve reviewed your application my assistant will reach out to you with the next step, if I determine that you are a good fit for my practice. Please know that while I would love to work with everyone, it is simply not possible. I must limit my practice to only those who are fully committed to restoring their health.

Questionnaire

Your Name (required)

What is the best number to reach you? (required)

Email Address (required)

What major health issues are you dealing with?

How many different physicians/providers have you worked with on these concerns?

What is your TOP challenge you are looking for help with?

Why is this goal important to you?

Be honest…What is stopping you from accomplishing this goal?

If you were to wake up tomorrow without this challenge, how would your life be different?

On a scale of 1-10 how willing are you to work on and make changes in:
Your diet:
Your activity level:
Stress reduction:

How much of a financial investment are you prepared to spend to achieve your health goals?
$100-$1000$1000-$5000$5000-$8000Whatever it takes!

Why do you want to work specifically with Dr. Karney?

Are you able to travel to Crystal Lake, Illinois for your first visit?
YESNO

Who is your primary care physician?

Is there anything else you think I should know about you?