Personal Health Assessment
* Required
1. How would you describe your Day to Day energy levels?
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Poor
Unsatisfactory
Satisfactory
High Energy
2. My bodyweight is appropriate for my frame.
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Agree
Disagree
Unsure
3. I sleep soundly and wake up in the morning feeling refreshed.
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Always
Usually
Sometimes
Never
4. I consider my self-esteem and self-acceptance levels to be...
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Poor
Unsatisfactory
Satisfactory
Excellent
5. I make time for myself daily so that I can focus on my health and well-being.
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Always
Usually
Sometimes
Never
6. I feel that I am strong in my beliefs and follow through on my self-commitments.
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Always
Usually
Sometimes
Never
7. I positively need to be in the best shape to live my best life.
*
Agree
Disagree
Unsure
Your Name (required)
*
Your answer
Your Email (required)
*
Your answer
Your Phone Number (required)
*
Your answer
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This form was created inside of Manifest Weight Loss.
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