Patient Application Form
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Email *
First Name *
Last Name *
Address
Phone Number *
Age *
What is Your Main Health Concern? *
If you have any other health issues, what are they?
What would be the ONE THING you wish achieve in regards to your health over this next year? *
Why do you think you haven't achieved this result yet? *
How many health care providers have you consulted with for this problem? *
Working with Deborah is a four figure investment in your health. Are you prepared to do what is necessary in time and resources to get to the root of your health problem and start healing? *
SLEEP- How much sleep do you get every night? Do you remember your dreams? And do you wake up energized? If you have trouble falling or staying asleep, or if you take any sleep aid, please describe:
EXERCISE- Do you exercise? If so what do you do, for how long and how often? If not, why not?:
DIET- Do you follow any special diet? If so, what is it? Please describe your daily food intake, including fluids, and list any food allergies or sensitivities:
MEDS- Do you take any medications, including over the counter drugs? If so, what and why?
SUPPLEMENTS- Do you take any supplements? If so, what and why?
Are you taking Genesis Gold? For how long? How has Genesis Gold helped you?
How did you find us? If someone referred you, please share their name. *
If there's anything else you wish to share, please do so below:
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