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* 1. Have you ever fasted before?

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* 2. If yes, why?

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* 3. If yes, when and for how long?

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* 4. What did you consume while fasting? Check all that apply.

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* 5. Did you consume anything else? Please describe:

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* 6. What are your goals for this YouHealing Program?

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* 7. Physical Goals:

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* 8. Emotional Goals:

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* 9. Spiritual Goals:

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* 10. Other concerns and/or goals?

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