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Living Vital Now -Client Discovery Form
Foundational information to build your wellness path.
Kate Richards-Wellness Consultant
livingvitalnow@gmail.com
Living Vital Now -Facebook
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Email
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Full Name
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Date of Birth
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Let's get specific-please choose each area of concern that applies to you
fatigue/low energy
headaches/ migraines
stress related challenges
digestive discomfort
low libido
recurring uti/vaginosis
muscle pain
neuropathy/ nerve pain
depression
anxiety
hot flashes/ menopausal symptoms
weak immune system
leg crapms
poor quality sleep
recurring sinus issues
Option 16
None
Your answer
Your answer
If you selected 'digestive discomfort' please let me know more specifically about your imbalance
heart burn/acid reflux/indigestion
lower abdominal pain
excessive gas
ulcers
diarrhea
liver or gall bladder issues
diverticulosis or diverticulitis
food allergies
chronic constipation or painful bowel movements
hemorrhoids
IBS/ Crohns diagnosis
gi surgery
fatty liver diagnosis
Option 11
Other:
Your answer
Your answer
Do you feel that you are properly hydrated?
I drink 16-24 oz. of water a day (2-4 glasses)
I drink 24-32 oz of water a day (4-6 glasses)
I drink 32-48 oz of water a day (6-8 glasses)
Option 4
Clear selection
Want to be low carb eventually
Your answer
I am interested in knowing more about -
Nutirents to support my overall health
supporting my immine system
repairing my digestive system
reducing my pain
regaining my vitality in everyday life
managing my stress and anxiety
increasing my stamina as an athlete (or in my daily life!)
improving my libido
reviving my hair skin and nails
restoring my joint or skeletal health
learning more about healthy hormone balance through menopause or andropause
Please let me know if there are other concerns or questions that you did not see a space for in this discovery form
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