HEALTH INTEREST FORM

Thank you for taking the time to complete this information that tells me a little bit more about you and how we can possibly work together!

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* 1. Some Information about You!

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* 2. How would you rate your current state of health on a scale of 1-10:  1 being terrible, 10 being the best it could be?

0 10
i We adjusted the number you entered based on the slider’s scale.

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* 3. What is(are) your main health concern(s) at this time?

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* 4. List 3 ways your present health concern is affecting your life.

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* 5. What will happen if you chose not to address your health concerns?

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* 6. Why do you want help now to address your health concern?

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* 7. Describe any efforts you’ve tried in the past to solve your main health concern.  Include why they worked and for how long or why they didn’t. 

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* 8. What are the main challenges you experience in your day to day life that are keeping you from achieving your goal?

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* 9. If you could remove any thoughts, limitations or challenges that you feel are stopping you from committing what would they be?

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* 10. On a scale of 1-10 how committed are you to learning and making the changes you need to make so you can reach your goal?

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i We adjusted the number you entered based on the slider’s scale.

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