Kelly Pryor - Health Works
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Date of Birth
Please enter a valid phone number.
Preferred method of contact:
Do you have any food allergies? If yes, please describe:
What time do you usually go to bed at?
What time do you usually wake up at?
How many hours of sleep do you usually get?
How is your quality of sleep?
Do you wake up feeling rested?
How much water do you drink in a day?
How much coffee do you consume in a day?
How much alcohol do you drink in a week?
How many times a week do you exercise?
What kind of exercise do you participate in?
Are there things you would like to do, that you currently are not physically able to?
How would you rate your daily energy level?
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
How would you rate your stress level?
When do you eat your first meal?
When do you eat your last meal?
How many meals per day do you eat?
Do you snack? If yes, on what?
How often do you eat out in a week?
Where do you eat out at?
What is your height?
Have you tried to lose weight before?
If yes, what have you found most difficult about losing weight in the past?
Thank you! I will be in touch with you shortly. You can also email me at firstname.lastname@example.org.
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