Please fill out the Health Quest

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* 1. How much weight would you like to lose if you
could not fail?

 When was the last time you were at that weight?

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* 2. Do you have any doctor diagnosed health issues or
prescribed medications? 

 If yes, Please describe:

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* 3. What is your age?

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* 4. Do you have any food allergies?

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* 5. How many ounces of water do you drink per day?
(typical bottle is 16.9 oz.)

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* 6. How often do you eat out weekly?
(Restaurants, Fast Food?)

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* 7. When do you typically have:
 Breakfast:_____AM   Lunch:_____PM   Dinner:_____PM?

   What do you typically have for Breakfast? ­­


   What do you typically have for Lunch?

   What do you typically have for Dinner?

   What do you typically have for Snacks?

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* 8. Rate your Stress level - 1 (low) – 10 (very high)?

 Rate your Energy level - 1 (low) – 10 (very high)?

 How many hours do you sleep? ______
 Is it quality sleep?

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* 9. How ready are you to lose weight -
1 (low) – 10 (very high)?

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* 10. What is your full name?
 What is your phone #

 What is your email address?

 Thanks for filling this Health Assessment out. Your answers will help evaluate which part of our program would be most effective in getting you to optimal health. I will be contacting you soon to set up a time when we can have a brief phone call. Believing for your healthy future!
 Francis

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