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Healthy starts in the kitchen
First Name:
Last Name:
Email:
Number:
work:
Address:
Age:
Height:
DOB:
Current Weight:
Weight before 3 months:
12 months ago:
Do you want to lose weight?
How much?:
Relationship status :
Children:
Occupation:
Hours per week:
List any health problem:
Any serious illness/hospitalizations/injuries/any concerns?:
How is/was your mother health?
How is/was your father health?
What is your blood type?
How many hours do you sleep?
Do you wake up at night?
why?
Any pain/swelling?
Any gas/constipation/diarrhea?
Allergies/ sensitivities?
Any major health concern:
Do you take any medications/supplemnets:
What are your diet these days?
Breakfast:
Snacks:
Lunch:
Dinner:
Liquids:
Do you eat home cooked meals?:
Any additional comments or any information you like to share:
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