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Month
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Day
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Date
Name
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Who referred you?
If you were referred, please put the name of the person who referred you OR where you saw this link.
What would you like to accomplish with your health?
Remember, where you begin does not determine how far you can go! Transformation is possible!
Do any of the following medical conditions and/or medications apply to you?
*
Diabetes Type I
Gluten Intolerance/Allergy
Diabetes Type II
Soy Allergy
High Blood Pressure
Food Allergies
Thyroid
Gout
Coumadin (Warfarin)
None
Lithium
GLP-1
Other
Are you pregnant?
*
Yes
No
Are you nursing?
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Yes
No
On a scale of 1-10, how would you rate your current well-being? (Physical health, mental health, relationships, etc.)
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NOT SO GOOD
1
2
3
4
5
6
7
8
9
GREAT!
10
1 is NOT SO GOOD, 10 is GREAT!
When you wake up most mornings, do you feel rested? If not, what factors are impacting the quality of your sleep?
*
What comes to mind when you think about exercise?
*
What would you say is the primary obstacle standing in the way of your health goals?
*
Let's talk about your dreams for the future.
It may be difficult to see right now, but the life you are dreaming of really is possible. And I'm honored to help you get there!
When you reach your health goals, how will your body look & feel?
*
What opportunities or experiences will you pursue as your healthier self?
*
What specific measurable outcomes (e.g., weight, fitness levels, lab results) will you see when you reach your goals?
*
Is there anything else you'd like me to know?
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