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Wellness Nutrition Questionnaire
My Current Weight
My Ideal Weight
Are you currently taking any medication?
Do you have a lack of energy?
Do you have trouble sleeping?
Do you exercise once a week or more?
Do you have any of the following issues?
Flatulence (Lots Of Gas)
IBS (Irritable Bowel Syndrome)
Is there a specific reason or occasion why you want to do our program?
Have you tried any other health programs before and if so, which ones?
Do you have a history of any of the following?
High Blood Pressue
How did you hear about our Wellness Nutrition Program?
Are you falling asleep after lunch/dinner?
Preferred method to be contacted?
Phone Call (8am-11am)
Phone Call (2pm-5pm)
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