Kyla McComas
Health & Wellness
Personal Information:
Full Name
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First Name
Last Name
Phone Number
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Format: (000) 000-0000.
E-mail
*
example@example.com
AWAKEN
Describe yourself in few words.
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What would you like to accomplish with your health? This could be weight-loss, improved sleep, better response to stress, etc.
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What is your main motivation for wanting to make changes to your health? Relationships, activities, how you feel, etc.
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Can you tell me about a time in your life when you were healthier? What has changed between then and now?
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Daily Routine & Habits
How many ounces of water do you drink per day?
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10-20 oz
30-40oz
50-70 oz
70 +
How many meals & snacks do you eat per day?
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1-2
3-4
5-6
7+
What areas of your life tends to be the biggest stress for you?
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Home Life
Work
Family
Lifestyle
Is there anything else you think I should know about your health?
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Submit
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