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Assessment
Please Answer this form as truthfully as possible:
10
Questions
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1
Name
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2
Email
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3
How Healthy do you eat?
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Congrats on making your choice to feel Amazing all throughout the day! Do you feel you eat healthy?
Yes, all the time
Yes, but I have a cheat 1-3x per week
Yes but I cheat daily
Sometimes/Not sure
No, but I try to eat a healthy meal daily
No, but I try to eat healthy often
Not at all
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4
What kind of diet do you consider healthy
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(Check all that apply)
Low carb/Keto
Low fat
Intermittent Fasting/OMAD
Vegetarian/Pescatarian/Mediterranean
Paleo
IIFYM
American/Canada Food Guide
Not Sure
High Protein
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5
Do you currently consume coffee/caffeine?
Please select the best answer
Yes, all thru the day (more than 3x)
Yes, a couple times per day
Yes, once a day typically
Yes, a couple times per week
Yes, but infrequently
No, Not at all
Yes, but only before an event/activity
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6
Can you tell us of any history or pre-existing health conditions you have had in the past?
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(i.e. high blood pressure, seizures, myopathies, hypoglycaemia, diabetes, thyroid disorders etc)
*By providing these conditions you declare them to be true.
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7
Are you on any medications? If so what are they for?
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*By providing these conditions you declare them to be true
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8
Take Photo
Submit your photo now, then again in 2 weeks so you see changes yourself.
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9
I attest that the information provided is accurate and to the best of my knowledge. (Print Name)
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10
Signature
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