Love & Serve WELL Health Evaluation
It’s an honor to chat with you about your goals and hear more about WHY you want to move forward in your health!! We will also talk about WHO… who would be impacted by your YES to starting this journey? Thanks for sharing this info so I will already be a little informed for our conversation. ☺️ Brittany
Full Name
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First Name
Last Name
Address
Street Address
Address 2
City
State / Province
Postal / Zip Code
Phone Number
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E-mail
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example@example.com
How did you hear about us?
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Age
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What do you want? Health Goals / Motivation? (weight, muscle, energy, etc.)
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How will your life change when you accomplish what you want?
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What have you tried in the past?
What do you believe has created the struggles you're experiencing?
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Health conditions you take meds for / food allergies (Weight loss meds, Diabetes, High Blood Pressure, Thyroid, Cholesterol)?
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Tell me about your sleep:
What you drink daily / how much? (Water, Coffee, Soda, Alcohol, etc.)
Biggest struggles with food?
How often do you eat out?
Describe your activity/exercise/motion (Frequency, Intensity, Duration):
Rate your stress (scale of 1-10). Primary source of stress?
Current Height/Weight? What's a healthy weight for you?
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Who would like to get healthy with you?
Submit
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