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* 1. Name (required)

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* 2. Overall nutrition during the last 7 days INCLUDING WEEKENDS

1 (worst) 5 (middle) 10 (best)
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 3. How many days have you done 45 minutes or more of activity this week?

0 (days) 3 (days) 7 (days)
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 4. Overall stress level

0 (no stress) 5 (moderate stress) 10 (extreme stress)
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 5. Average water intake over the past 7 days total oz. per day

(0 oz.) (50 oz.) (100+ oz.)
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 6. Average hours of sleep over the past 7 days

(0 hours) (5 hours) (10 hours)
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 7. Overall effort towards reaching your health and fitness goals

0 - (did not try at all) 5 - (moderate effort) 10 - (did my absolute best)
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 9. Comments from any questions above.

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* 10. Do you have any concerns, complaints or suggestions on how to improve our services at OC Fitness Coach?

T