Name
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First Name
Last Name
Email
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Phone
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Gender
Age
Height
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Weight
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What do you do for a living?
Activity Level
What is your main health goal?
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Do you have any secondary health goals and if so, what are they?
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What have you tried before to reach your goals and why do you feel it didn't work for you?
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How many meals do you typically eat per day?
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What times do you typically eat your meals?
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Do you generally snack? If so, how many times per day and what are your preferred snacks?
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Do you prefer to
Please list any known food allergies, dietary sensitivities, and/or foods you prefer to avoid for any reason:
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Approximately how many ounces of water do you drink daily?
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Please list any current supplements
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Do you consume any beverages other than water? If so, please list them and approximate daily quantities.
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Do you lack energy at any specific point in the day? If yes, when?
On a scale from 1 - 10, how ready are you to change?
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2
3
4
5
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8
9
10
What is your motivation or the driving factor behind your desire to change?
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What do you need the most help with right now?
Are you ready and willing to commit to changing your life, right now?
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What is your preferred contact method?
Disclaimer & Privacy Policy
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I acknowledge Eat for Wellness LLC provides wellness education and does not provide any medical advice. I acknowledge that I should work with my physician or other trusted medical provider prior to beginning any diet, exercise, or wellness program. I further acknowledge that I have read and agree to the disclaimer and privacy policy which can be found in the page footer below.
