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* 1. What is your name (please include first and last names)?

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* 2. What email address may we use to contact you? (Please ensure this is correct!)

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* 3. I'd love to know where you are located. If you live within the US, in what state or territory do you live? And what city or town do you currently live in?

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* 4. I'd love to know how you specifically found me or who referred you. (Personal referral, video, live event, website, other and please be specific.)

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* 5. What are your main goals for seeking nutrition counseling with Essentially Healthy? (Select all that apply)

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* 6. Do you have any health or medical conditions or diagnoses that I should know about in helping you to find the best care? If yes, please explain.

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* 7. What have you tried so far to address your goal? (Diets, testing, modalities, etc.)

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* 8. Which of the following items are currently in your diet in ANY amount: (select all that apply)

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* 9. What percentage of your meals are currently home cooked?

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* 10. I am committed to working with individuals who are dedicated to their health and ready to receive support on their individualized journey. I am uniquely poised to uncover and unlock the evolving diet and lifestyle modifications that will deliver the results you've been seeking. In two or three sentences, tell me something about yourself and/or your health history that will help me to get to know you before we take any further steps to dig more deeply into the details of your concerns. Once I receive your survey, I will be in touch to schedule your complimentary Strategy Session.

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