Questionnaire

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* 1. What is your first and last name?

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* 2. What is your email address?

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* 3. What is your mailing address? (If you’d like samples and some resources).

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* 4. How did you receive this questionnaire? (List website, account or name of the wellness coach)

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* 5. Health concerns/topics of interest (check the ones that apply):

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* 6. Other concerns/topics of interest:

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* 7. How would you like to connect?

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* 8. What is your phone number if you prefer being contacted by phone?

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* 9. What is your name on Faceook if you'd like to connect there and be added to our education group?

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* 10. Would you like to be added to our newsletter to learn more tips, recipes, and when future online or in person classes are happening?

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