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ELIMINATE Your FIBROIDS and/or INFERTILITY Issues in 90 Days!
Full Name:
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Email Address:
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Mobile Number:
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Full Address:
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Age
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How Did You Hear About Us/Our Program? (Check All That Apply)
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How Do You Feel About Incorporating Prayer & Scripture Into Your Coaching?
Which Best Describes Your Issue?
If you have Fibroids, how many and what sizes are they according to your most recent test and what date did that take place?
As much as possible, please provide exact details on the number, size and location if known.
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Medical Overview of Your Story/Case
Please include dates to provide a timeline where possible--also identifying any surgeries and/or advanced reproductive technology treatments (such as IUI or IVF) you have undergone.
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What is Your Current Physical Condition?
Symptomatic
Asymptomatic
What Are Your Most Severe Symptoms?
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What Is Your Current Emotional Condition?
Fearful
Happy
What is the Main Driver of Your Emotional Condition?
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What is Your Current Spiritual Condition?
Hopeless
Hopeful
What is the Main Driver of Your Spiritual Condition?
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Do You Exercise Regularly And if So How Often and What Kind of Exercise?
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What Best Describes Your Diet?
What Time Zone Are You In and What Times of Day Monday through Friday Are You Available for Coaching Sessions ?
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What Best Describes Your Budget for This Treatment?
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Do You Have Any Other Medical Issues That We Should Be Aware Of?
Please Check ALL That Apply.
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What, If Any, Medications Are You Currently Taking and What Do They Treat?
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