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  • PERSONAL APPRAISAL

    The following questionnaire is a comprehensive look at your health. Please take the necessary time to complete
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  • GENERAL INFORMATION

  • What is your strategy for relaxation? 1 - 10 (1=least likely / 10=always)

  • Next: Dietary Style . .



    • Womens Health  

    • Patient health history

  • Part 1

    Section A

  • HEALTH APPRAISAL

    DIRECTIONS: This questionnaire asks you to assess how you have been feeling during the last four (4) months. This information will help you keep track of how your physical, mental and emotional states respond to changes you make in your eating habits, priorities, supplement program, social and family life, and level of physical activity. All information is held in strict confidence. Take all the time you need to complete this questionnaire. (1=no/rarely - scale to- 4=frequently)
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  • Part 1

    Section B
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  • Part 1

    Section C
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  • Part 2

    Section A
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  • Part 3

    Section A
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  • Part 3

    Section B
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  • Finish Up

    Please Sign
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