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Welcome

Welcome! We appreciate your time and participation. Please fill out the form and answer to the best of your knowledge. Thank you for contribution!

First name

Last name

Phone

Birthday

Month

Day

Year

Address

What is your main wellness goal?

What is your biggest wellness concern?

How many hours of sleep do you get per night?

Have you tried diets or other treatmets? If so, please tell me about it

Please describe your meals during one weekday (Example: Breakfast, Two Eggs and one glass of milk, Snack - One apple, etc)

How do you relax?

What is your favorite thing to do for fun?

How ofthen do you workout?

Once a week

Two or Three times a week

Everyday

Never

Do you have food allergies? If so, please tell me about them

Do you have digestion problems?

Do you have any medical issues I need to know?

How often do you eat vegetables

Do you eat while wacthing TV?

Do you eat when under emotional stress?

Do you eat fast?

Do you like to cook?

Do you drink alcohol?

Do you have family/friends support?

Date picker

Schedule an appointment

January 2026

Week starting Sunday, January 25

Time zone: Coordinated Universal Time (UTC)Phone call

Wednesday, Jan 28

10:00 AM - 11:00 AM

11:00 AM - 12:00 PM

12:00 PM - 1:00 PM

1:00 PM - 2:00 PM

Signature

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