Contact Information

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* 1. Contact Information

How old are you? 

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* 2. How old are you? 

How tall are you? 

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* 3. How tall are you? 

What is your current weight? 

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* 4. What is your current weight? 

What was your weight a year ago? 

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* 5. What was your weight a year ago? 

What is your current relationship status?

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* 6. What is your current relationship status?

Do you have any children?

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* 7. Do you have any children?

What do you do for work?

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* 8. What do you do for work?

How many hours a week do you work? 

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* 9. How many hours a week do you work? 

do you like your job? 

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* 10. do you like your job? 

At what point in your life did you feel best about yourself, both physically and mentally? Explain Why

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* 11. At what point in your life did you feel best about yourself, both physically and mentally? Explain Why

Have you ever had a serious illness/hospitalization or injury? 

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* 12. Have you ever had a serious illness/hospitalization or injury? 

How many hours do you sleep on average a night?

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* 13. How many hours do you sleep on average a night?

How is your sleep? 

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* 14. How is your sleep? 

Do you wake up in the middle of the night? 

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* 15. Do you wake up in the middle of the night? 

How is your digestion?

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* 16. How is your digestion?

What blood type are you? 

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* 17. What blood type are you? 

Do you have any pain, stiffness or swelling in any of your joints, back, etc.?

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* 18. Do you have any pain, stiffness or swelling in any of your joints, back, etc.?

If you answered yes explain...

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* 19. If you answered yes explain...

Any allergies or sensitivities? 

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* 20. Any allergies or sensitivities? 

Do you take any supplements or medications? if so what? 

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* 21. Do you take any supplements or medications? if so what? 

How many hours a week do you currently exercise on average? 

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* 22. How many hours a week do you currently exercise on average? 

would you like to exercise more? is the answer is yes please explain what is stopping you.

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* 23. would you like to exercise more? is the answer is yes please explain what is stopping you.

What is your typical breakfast? 

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* 24. What is your typical breakfast? 

lunch? 

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* 25. lunch? 

Dinner? 

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* 26. Dinner? 

snacks? 

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* 27. snacks? 

How many glasses of water do you drink on average a day? 

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* 28. How many glasses of water do you drink on average a day? 

do you drink coffee?

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* 29. do you drink coffee?

Do you drink soda or energy drinks?

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* 30. Do you drink soda or energy drinks?

Would your family and friends be supportive of your desire to lead a healthier lifestyle ?

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* 31. Would your family and friends be supportive of your desire to lead a healthier lifestyle ?

do you smoke cigarettes or deal with any other major addictions? 

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* 32. do you smoke cigarettes or deal with any other major addictions? 

Do you know how to cook?

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* 33. Do you know how to cook?

What percentage of your food is home cooked?

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* 34. What percentage of your food is home cooked?

Where do you get the rest of your food from?

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* 35. Where do you get the rest of your food from?

What is the most important thing you should improve in your health? 

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* 36. What is the most important thing you should improve in your health? 

How much are you willing to spend on improving your health? (monthly)

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* 37. How much are you willing to spend on improving your health? (monthly)

anything else you would like to share? 

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* 38. anything else you would like to share? 

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