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Wellness Questionnaire
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Indicates required field
Name
*
First
Last
Email
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Phone
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Street Address
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City, State, Zip
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Age
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Birthday (MM/DD/YY)
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Height (Example 5'1")
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Current Weight
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Relationship Status
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Number of Children
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Number of Pets
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Occupation
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Hours Worked Per Week
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Please customize my program with the following considerations. I have:
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High Blood Pressure
High Cholesterol
Diabetes
Thyroid Challenges
Lupus
Cancer
Cancer Survivor
Acid Reflux
Constipation
Sweet Cravings
Carbohydrate Cravings
Allergies
Arthritis
Fibromyalgia
Check all that apply.
Blood Type
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Are you currently taking any nutritional supplements or medications?
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Yes
No
If yes, please list what you are taking and why. (Example: Biotin for brittle nails, 5 hour energy drink for energy, Coumadin because of a previous heart attack, etc)
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I would like help with making improvements in the following areas:
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Heathier Eating
Meal Planning
Eating on the run
Preparing healthy meals when I don't like to cook
Juicing
Detoxification
More Energy
Improved Libido
Managing Headaches/Migraines
Joint Pain
Hormonal Imbalances (Hot Flashes/Night Sweats)
Memory Loss
Hair Loss
Depression
Fluid Retention
Gas/Bloating
Finding exercises that I enjoy
Finding accountability partners
Finding exercise partners
Gain Weight
Regulate my eating schedule
Eating to help manage a specific condition/ailment
Inflammation
Back Pain
Lose the belly, keep everything else
Other
Check all that apply.
If other, please explain your needs/challenges here.
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How Did You Hear About This Site
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Internet Search
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Facebook
Twitter
Linked In
Comcast Channel 25 (Baltimore, MD)
Try A Little Tenderness TV Show
Referral
Other
Your phone consultation will take approximately 30 minutes. When would you like to be contacted for your phone consultation?
*
Today Anytime
ASAP
Mornings - 9 am -11:59 am
Afternooons - 12:00 pm - 4:59 pm
Evenings - 5:00 pm - 9:00 pm
Saturday
Sunday
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