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THE INTAKE FORM
*Confidential – For Internal Clinical Review Only**
Please complete this form as fully and honestly as possible. All information will remain confidential and will be used to assess your eligibility for HRT (Hormone Replacement Therapy).
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SECTION 1: PERSONAL INFORMATION

FULL NAME:
 *
DATE OF BIRTH: *
MM
/
DD
/
YYYY
EMAIL ADDRESS: *
Age *
What are your wellness aspirations? (i.e. fitness, nutrition, mindset, hormonal balance) *
What do you feel like is keeping you from reaching your goals on your own? *
What is motivating you to take this path now? *
What are the key values you are looking for in a coach? *
Do you have any medical conditions or restrictions I would need to be aware of? If so, are you under a doctor's care? *
Is there anything else I should know about you? *
What type of investment in yourself are you willing and able to make to achieve your goals? *
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