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Name (first and last) *
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Age *
Approximate current weight *
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Why do you want to adopt a Ketogenic Lifestyle? Check all that apply. *
Describe your struggle with weight. Check all that apply. *
Do you have (or have you ever had/been treated for) disordered eating? *
Do you have any medically diagnosed, pre-existing health conditions that contraindicate a Ketogenic Lifestyle? (ie. people kidney damage, heart disease, pregnant or nursing, type 1 diabetes, liver or pancreatic condition, gallbladder removal) *
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