Place of Birth
Weight 6 Months Ago?
Weight 1 Year Ago?
Would you like for your weight to be different? If so, what weight?
What are your main health concerns?
Are you seeing or have you seen any medical doctors, chiropractors, or therapists for your current concerns? Please list:
Any Helpers, Healers or Holistic Health Providers?
In what areas do you need help with your nutrition & lifestyle change?
Yoga & Meditation
Do you currently, or have you ever had, any of the following condition(s)?
High Blood Pressure
None of the Above
How frequently are you physically active per week?
How many hours of sleep do you get a night on average?
Which best describes your current diet?
What is the diet/lifestyle you would like to achieve?
Will family/friends be supportive your your lifestyle changes?
The most important thing I should do to improve my health is:
Anything else you would like to share?
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