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Health Assessment

Health Assessment

This form is confidential and will take 5 minutes to complete. It's designed to gauge your current health and to understand your goals. It's a starting point. That's all. After submitting, you will have the opportunity to schedule your free (no pressure or obligation) consultation to see if working together is the right fit. I'm excited to collaborate with you on your wellness journey.
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    Pick a Date
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    If you don't know your current weight, please provide what you think you currently weigh.
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    Sorry men.
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    What feels out of control right now?
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    Stress management is something we will focus on if we work together.
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    This is a fun question to look back on in a few weeks after getting started!
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    This includes beverages (Starbucks, alcohol, anything that goes in your mouth). Please include when you have your first meal of the day and how many times you eat throughout the day.
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    The average American spends over $15/day on their food and beverages. Don't forget about take-out/dining out/beverages/alcohol.
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    If you don't currently move your body, that's OK! If you are currently incorporating healthy motion into your week, please let me know how many times per week.
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    Please Select
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    • Outgoing
    • Reserved
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    Please Select
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    • Task-oriented
    • People-oriented
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    HORRIBLE
    EXCELLENT
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