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1. On a scale of 1-10, rate the state of your current physical, mental and emotional health?*

1 10
i We adjusted the number you entered based on the slider’s scale.

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2. What's the single greatest health challenge you're struggling with right now?*

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3. What obstacles are preventing you from enjoying the physical and mental health you know you deserve?*

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4. What specific daily symptoms do you notice (physically and mentally) that are preventing your optimal health?*

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5. What treatments have you previously tried, but didn't give the optimal health results you wanted?*

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6. On a scale of 1-10, at what level has your health challenge reduced your productivity in personal and professional life?*

1 10
i We adjusted the number you entered based on the slider’s scale.

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7. On a scale of 1-10, how coachable and committed are you to try an alternative TREATMENT PLAN to eliminate your physical and mental health challenges?*

1 10
i We adjusted the number you entered based on the slider’s scale.

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8. If there are any other facts or concerns about your health challenges that would give us more insight about your health challenges for our forthcoming Discovery Session, please write them in the space provided below*

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Full Name*

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Primary Email*

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