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First Name *
Last Name *
Email *
Phone *
What is your main health complaint? *
How often does it bother you? *
Everyday
Once per week
2 to 3 times per week
Once per month
How long has it been going on? *
1-6 months
1-3 years
Over 3 years
What (or who) would prevent you from completing a health-rebuilding or weight loss program?
Children
Spouse
Time
Self
Money
Resources
Job
Fear
What have you tried so far that has or has not worked? *
What is your current diet like? Please be specific: list breakfast, lunch, dinner and snacks, as well as the times you eat. *
Are you taking any supplements or medications? Please list what you take and what it's for. *
What would you like your health to be in 3 months from now? How about 6 months from now? *
What obstacles, challenges, and struggles do you face regarding diet/lifestyle? *
If we were to work together what would you expect to achieve from working with me? *
What are 5 things you LOVE about your life? *
Yes! I want to get awesome health tips, tools and resources
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