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* 1. Please include the following below; Name, Full Address, Age, Height, Weight.

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* 2. Gender

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* 3. Emergency Contact: Please include their full address, phone number and state their relationship to you

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* 4. What are your concerns and goals? (gain/lose/maintain/portion control) What do you think has kept you from meeting them?

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* 5. Family history and health concerns. Be sure to include any allergies you may have and list any medications you currently take on a daily basis:

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* 6. Do you currently eat breakfast daily? If so, what is a typical breakfast for you? Are there any foods you dislike or refuse to eat? Be specific.

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* 7. Are their any dietary restrictions? If so, please explain. (I.e., Poultry only, Pescatarian, Vegetarian/Vegan; Are you vegan, lacto-ovo etc). Do you choose poultry, fish, red meat, pork or fried foods in most situations?

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* 8. On average, how many servings per day do you consume of garden type vegetables (ex. carrots, tomatoes, broccoli, cauliflower, peppers, romaine lettuce, spinach, collard greens, kale)? NOTE: each of the following is equal to one serving: ½ cup of most vegetables 1 tomato 1 large stalk of broccoli 8 oz. of food cooked in tomato sauce 1 large cauliflower floret 1 small garden salad 8 oz. of vegetable juice 8 oz. of vegetable soup

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* 9. What are your favorite seasonings?

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* 10. What is your favorite dish?

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