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What is your main health complaint?
How often does it bother you?
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Everyday
Once per week
2 to 3 times per week
Once per month
What (or who) would prevent you from completing a health-rebuilding or weight loss program?
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Children
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Time
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How long has it been going on? *
1-6 months
1-3 years
over 3 years
What have you tried so far that has or has not worked?
What is your current diet like? Please be specific: list breakfast, lunch, dinner and snacks, as well as the times you eat.
Are you taking any supplements or medications? Please list what you take and what it’s for.
If we were to work together what would you expect to achieve from working with me?
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