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Wellness Intake Form
Give us your blood, sweat, and history! Our goal is to create a baseline of strengths and weaknesses, find out where you want to improve and then make it happen! Be as prolific as you want, this information is confidential. And THANK YOU!
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What is the level of your overall health?
Poor
Fair
Good
Very Good
Excellent
Other:
Clear selection
Fitness - How would you rate your overall fitness?
Don't work out at all.
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9
10
Ironman ready!
Clear selection
What is your biggest challenge when it comes to fitness?
Your answer
What do you know you need to improve?
Your answer
Nutrition - Rate your nutrition level. A 10 is feeling awesome, eating fresh organic fruits and veggies, no sugar, no alcohol, no caffeine and amazing energy levels!
I need help!
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9
10
Food is my fuel and I feel amazing!
Clear selection
What is your biggest challenge when it comes to eating?
Your answer
What can you do to improve your diet?
Your answer
Stress - Rate your daily level of stress.
Unable to sleep well, worried all the time.
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9
10
Chillin like I'm on a boat in the Riviera!
Clear selection
What is your biggest challenge when it comes to handling stress?
Your answer
What do you need to improve? (i.e. meditation basics, etc?)
Your answer
Feel free to write in any final thoughts, challenges you're dealing with or other requests you may have. Thank you for your participation!
Your answer
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