Ag Women's Wellness Club Intake Form
Name
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First Name
Last Name
AGE
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HEIGHT
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WEIGHT IF you feel you would like to focus on it
Ideal body weight, where do you FEEL your best?
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What are your top 3 goals related to health, wellness, nutrition and the like?
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What supplements and medications are you currently taking?
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Do you have any relevant medical diagnoses?
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Tell me what you currently do for exercise, if anything + your average steps/day if you know
Tell me about your sleep. Whats your bedtime? Wake up? Any middle of the night wakings that are unprompted by kids, husbands, or animals? What do the last two hours of your day look like?
How many ounces of water do you drink/day?
Do you drink caffeine daily? How much
Do you drink alcohol daily? How much?
What does your daily routine look like from wake up to bedtime? Include meals, snacks, habits, exercise, etc.
I understand that this program does not replace medical care
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Yes
Submit
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