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Nutritional Assessment
I Love Healthy Me
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Email
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Your answer
First & Last Name
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Your answer
Address
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1 point
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Telephone Number
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1 point
Your answer
Age
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Your answer
Email Adress
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Your answer
Weight
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Your answer
Height
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Your answer
Sex
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Female
Male
I would like to speak to an I Love Healthy Me Coach because?
Please provide a brief descriptionÂ
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My food and nutritional related goals are?
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Your answer
My health related goals are?
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Your answer
What medications are you taking?
Please provide a list of medications including vitamins, minerals and herbal supplements. If none of these just answer with N/A
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Your answer
If you could change 3 things about your nutritional habits they would be?
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Your answer
What's the biggest challenge reaching my nutritional goals?
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Your answer
In the past what diets, techniques, etc. have you tried to reach your goals?
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Your answer
On a scale of 1-5 please indicate your willingness to participate in the following below.
1 = you are NOT willing to participate
5 = you are willing to participate
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Your answer
Change your Diet
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1
2
3
4
5
Take alkaline hers each day
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1
2
3
4
5
Keep a food journal
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1
2
3
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5
Change your health lifestyle
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1
2
3
4
5
Practice relaxing
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1
2
3
4
5
My new life looks like
Give a brief description of what your new life would look like
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Your answer
I Love Healthy Me are not Medical Doctors, nor do we have a certified physicians on staff, we provide natural health and wellness alternatives and coaching to help individuals live healthier lifestyles
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