Pre-Consultation Intake — The McDaniel Institute

Section 1 — About You

First Name *

Last Name *

Email Address *

Phone Number

City & State

How did you hear about Dr. McDaniel?

Section 2 — What Is Going On Right Now

In your own words, what is the main reason you are seeking this consultation? What feels most urgent or most frustrating right now? *

How long have you been dealing with this? Has anything made it better or worse?

Section 3 — What You Are Experiencing Check everything that applies to you right now:

Other symptoms not listed above:

Section 4 — What You Have Already Tried

What have you already tried to address your health concerns? Include doctors, specialists, medications, supplements, diets, or other programs — and what helped or did not.

Have you ever been told "your labs are normal" but still felt something was wrong? If so, describe what you were told.

Section 5 — What You Are Looking For

What does "feeling better" actually look like for you? What would be different in your daily life? *

What is the biggest thing holding you back from being where you want to be with your health right now?

What made you choose to reach out to Dr. McDaniel specifically?

Section 6 — Your Readiness

Is there anything else you would like Dr. McDaniel to know before your consultation?

Appointment Confirmation

By submitting this form, I confirm that I have scheduled a consultation with Dr. McDaniel and I understand the following:

I will arrive on time for my scheduled appointment. If I am late, time will not be extended.

If I need to cancel or reschedule, I will provide at least 24 hours notice.

This consultation is a clinical conversation — not a diagnosis or treatment plan. A personalized protocol is developed through the WholeHer Restoration System™ following enrollment.

Information shared in this consultation is held in strict confidence by The McDaniel Institute.

I have read and agree to the above *

Pre-Consultation Intake Form

Thank you.