Intake Survey

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* 1. Who referred you?

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* 2. List your chief health concerns.

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* 3. Overall, would you be willing to make habit and/ lifestyle modifications to change your health outcome?

I am open to making 2-4 new habit changes a month with email/call support to help guide me.

I am open to making 2-3 new habit changes a month with email/call support to help guide me.

I am open to making one new habit change a month with email/call support to help guide me.

If I have to, I might.

I am not willing to make any habit or lifestyle changes at this point in my journey.

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* 4. What is your name?

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* 5. What is your best email for a Wellness Consultant to follow up with you?

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* 6. What is your best telephone number for a Wellness Consultant to follow up with you?