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Tell Me About Yourself
Congratulations on taking this bold step in your health journey! You are embarking on a transformational endeavor and your body will greatly reward you. Before we start we would like to get to know you a little better so we can offer you a customized care plan. Here are a few questions below. Looking forward to your responses😊
Full Name
Your Email Address
Age
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Sex
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Martial Status
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Weight (lbs/kgs) 
Height (ft/m)
What medications or pills are you currently taking?
To help us understand your health better, please list any prescriptions, over-the-counter medications, or other pills you're taking regularly:  

Are you taking any supplements, herbs, or nutritional drinks?
Let us know about any vitamins, minerals, or other health-boosting supplements you're incorporating into your routine:

What health concerns or challenges have you experienced lately?
(Feel free to share anything physical, mental, or emotional. We’re here to listen.)  

When was the last time you saw a physician?
(It’s great to stay up to date with regular check-ups!)

Are you currently being treated for any conditions?
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If yes, can you share which ones?

Any surgeries or major health events in the past?
(It's always helpful to know so we can better support your health)

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If yes, kindly describe

  Do you have any known allergies?  

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If yes, what are they?
LIFESTYLE HABITS
We believe your lifestyle plays a big role in your health. Let’s dive into some of the daily habits that shape your life.  
BREATHE EASY: HOW'S THE AIR AROUND YOU?  
The air we breathe affects our health and well-being. We’ll take a look at the quality of the air around you and explore ways to enhance it for better health.
Where do you spend most of your time?   *

Do you sleep with your windows open to let in the fresh breeze?  

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Do you open your windows and doors and let your home breathe?

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Is your environment clouded with smoke?

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Are there any smokers in your household?

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Does your house have indoor plants?

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Are there any places you spend time where fresh air is scarce?

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If yes, what are those places?

What’s your favorite way to get fresh air?   *
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On a scale from 1 to 10 how do you feel about the air quality where you live? *
Lowest
Highest
THE POWER OF SUNLIGHT: UNLOCKING YOUR VITAMIN D POTENTIAL
Let’s talk about your exposure to sunlight, which is key for both physical and mental health.  
How much sunshine do you soak in each day? *
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Do you sunbathe or enjoy sun exposure?  

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Do you use sunscreen, or have any skin sensitivities?

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Do you take Vitamin D supplements?

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MODERATION: STRIKING THE BALANCE IN YOUR LIFESTYLE
Finding balance in what we consume is key to maintaining a healthy, sustainable lifestyle. In this section, we'll explore how your habits align with moderation and self-control.
What is your current job title?
What types of jobs did you have in your career?
Do you currently use tobacco in any form (e.g., cigarettes, chewing tobacco)?  
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Have you used tobacco in the past?  
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If yes, for how long?  
Have you consumed alcohol in the past?  
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Do you consume alcohol?  
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Do you drink caffeinated beverages?  
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Which types do you drink?  
Do you find yourself overeating?
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Do you tend to eat too quickly?
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Do you chew your food thoroughly before swallowing?
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Do you snack in between meals?
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Do you eat at set meal times?
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Do you set aside time for leisure activities?
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Do you find yourself working too much?
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Are there any habits or substances you feel addicted too?
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Have you ever struggled with substance abuse?
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FUELING YOUR BODY: THE POWER OF DIET & NUTRITION
We know food is more than just fuel—it’s a big part of how we feel! Let’s talk about what’s on your plate.  
Do you include meat or seafoods in your diet (chicken, turkey, pork, fish, shrimp etc. )? *
Do you eat any dairy items or eggs (i.e. milk, cheese, yogurt, chocolate etc. )? *
Do you eat refined white products (White bread, white rice, white flour products, etc.)? *
How would you describe your typical meals?   *

Do you enjoy eating fruits and veggies?

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How many servings of fruits do you get daily?

One serving is typically about one medium piece of fruit (e.g., an apple, banana, or orange), or about ½ cup of fresh, frozen, or canned fruit.  

How many servings of veggies do you get daily?

One serving is about 1 cup of raw vegetables or ½ cup of cooked vegetables.  
Do you enjoy condiments with your meals?  (Ketchup, mustard, mayonnaise, BBQ sauces, pickles, salad dressings, etc.)  
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How often do you eat fried foods?  
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Do you use margarine or butter in your cooking?
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Do you indulge in chocolate, cocoa or ice cream?
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Do you use salt in your food?
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Does the salt you use contain iodine?
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What types of oil do you use when cooking?

Do you have any dietary restrictions or preferences?

How often do you eat out or try new foods?  

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What's your favorite type of cuisine?

How often do you eat sweets and snacks?  

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How often do you have a bowel movement?
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GET MOVING: ENERGIZE YOUR BODY WITH EXERCISE
Exercise doesn’t have to be a chore—it can be a joy! Let’s talk about how you move.  

Do you exercise and keep active?

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What's your favorite way to stay active?

How many times a week do you get your body moving?  (Let’s get those heart rates up!)

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How many minutes per day?

How would you rate your exercise? 

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Do you feel energized or tired after exercise? 

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RECHARGE & RESTORE: THE POWER OF QUALITY SLEEP
Good rest is essential for your health. Let’s see how your sleep habits are.  

What time do you usually go to bed?

Do you sleep through the night, or wake up at all?    

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How often do you wake up during the night?  

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 Are you getting enough rest to feel refreshed?  

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Is there anything you would like to improve about your sleep routine?

HYDRATE FOR HEALTH: THE POWER OF WATER
How many glasses of water do you drink on a typical day?
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What type of water do you drink?
How do you prefer your water?
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Do you drink liquids during your meals?
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What is the usual color of your urine?
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NURTURING YOUR SOUL: THE PATH TO SPIRITUAL WELLNESS
How you feel spiritually can have a powerful impact on your overall well-being.  

Do you set aside time each day devotion?  

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Is this something you would like to start or improve?  

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Do you read the Bible daily?
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Do you regularly return a faithful tithe and offerings?
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Do you find it difficult to trust God with your problems?
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Are you currently feeling any guilt, remorse, worry, or fear?  
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Do you believe you have experienced God's forgiveness in your life?
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How do you feel about your relationship with God? 

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Do you ever struggle to understand God's will for your life?
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Do you feel at peace with your life and your decisions?

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ADDITIONAL THOUGHTS & REFLECTIONS

We believe this is your journey, and we’re here to support you. Feel free to share anything else that’s on your mind—whether it’s a health goal, challenge, or any reflection from this questionnaire!

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