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* 1. What is your full name?

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* 2. What is your email?

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* 3. What is your age and height?

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* 4. What is your current weight in lbs?

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* 5. What is your goal weight in lbs?

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* 6. Please briefly describe your health and medical history. Be sure to include any areas of concern that should be considered when creating your custom nutrition starter pack.

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* 7. Please indicate that you agree to the following disclaimer by signing your full name in the text box below-

The information included in your custom nutrition starter pack is for informational purposes only. Your custom nutrition starter pack does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease, and those seeking personal medical advice should consult with a licensed physician.

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