Team Recharge: 30 Day Wellness Recharge Client Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
-
Area Code
Phone Number
Are you Ok with receiving text messages?
*
Yes
No
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
What is your main reason for joining the 30-day Wellness Recharge? Why do you feel you need to improve your health and wellness?
When you search deep in your heart, without taking account for anyone else, what would you say is the one thing you desire most for your health and/or for your life?
What are some of your current Meal/Snack habits? (for example: do you eat breakfast or skip breakfast? What time is your first meal of the day? Do you eat lunch at work? Do you pack a lunch? What time do you eat Dinner in the evening? Are meal times consistent day to day?) List any info. that will be helpful.
Do you have any food allergies?
Will you be exercising throughout the next 30 days? If so, what time of day and what will you be doing? It is important to properly fuel and refuel for workouts. Your physical activity will help me best plan your menu.
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