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Health Screening
Please answer these questions in as much detail as you can
Email *
What is your date of birth? *
MM
/
DD
/
YYYY
Name *
What is your occupation? *
What are your health and fitness goals? *
In your opinion, what is the biggest obstacle standing in your way? *
On the following scale from 1 to 10, where 1 is definitely not ready to change and 10 is definitely ready to change, what number best reflects how ready you are at the present time to change?
Definitely not ready to change
Definitely ready to change
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On a scale from 1 to 10, how important is it for you to meet your goals? *
Not Important
Most Important
How confident are you that you can overcome your obstacles and reach your goals? *
Not Confident
Certain
Have you tried any diets in the past? (Paleo, Vegetarian, Ketogenic, Vegan,) *
Required
Are you currently on any specific diet? *
1. When was the last time you had your blood work done? *
2. Have you been diagnosed with any of the following? *
Required
3. Are you currently taking any medication or nutritional supplementation? *
If yes please list all supplements and medications.
4. What type of exercise do you participate in currently? *
Required
Please check what interests you. *
Required
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