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47
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1
Name
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First Name
Last Name
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2
Mobile Phone Number
Area Code
Phone Number
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3
Email
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example@example.com
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4
How often do you check your email?
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5
Where do you currently live?
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What time zone is that?
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6
Height (please indicate if ft or cm):
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7
Age:
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8
Date of birth:
*
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Date
Year
Month
Day
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9
Place of birth (country) :
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10
Current weight (pounds or kg):
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11
Weight six months ago:
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12
Weight one year ago:
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13
Would you like your weight to be different?
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YES
NO
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14
If so, what?
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15
Relationship status:
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16
Children:
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17
Pets:
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18
Occupation:
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19
Hours of work per week:
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20
What food did you eat often as a child?
*
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Breakfast
Lunch
Dinner
Snacks
Liquids
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21
Is there anything else you would like to add?
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22
What is your food like these days?
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Lunch
Dinner
Snacks
Liquids
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23
Is there anything else you would like to add about your eating habits?
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24
Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions?
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25
What is the most important thing you should change about your diet to improve your health?
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26
Please list your main health concerns:
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We will go more in depth during our Health History Consultation
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27
Did you underwent any serious illnesses/hospitalisation/injuries?
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Please specify
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28
Are you taking any medications or supplements?
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Please specify
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29
What role do sports and exercise play in your life?
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30
Are you involved with any healers, helpers, or therapies?
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31
Do you struggle with any of those: heartburn, constipation, diarrhoea, gas IBS, indigestion?
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Or anything else happening with your digestive health?
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32
Do you experince any pain, stiffness, or swelling?
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33
Do you have any allergies or food sensitivities?
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34
What is your blood type?
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If you know it.
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35
What is your ancestory?
*
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Where does your parents and their parents come from?
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36
What is/was your mother health?
*
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37
What is/was your father health?
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38
Is there anything else you would like to share?
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39
Are your periods regular?
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40
How many days is your flow?
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41
How frequent?
Is it every 28 days? Or more or less?
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42
Are your periods painful or symptomatic? If so, please explain
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43
Have you reached or are you approaching menopause? If so, please explain:
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44
What is your birth control history?
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45
Do you experience yeast infections or urinary tract infections? If so, please explain:
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46
What is the one urgent issue you want to have addressed the most at this point?
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47
Would you like to receive further Newsletter from me in the future?
*
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Arleta Blackley-Wiertelak
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48
Tags
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