Date of Birth
What is your main health concern?
Do you have any allergies?
What have you done in the past to work on this health condition (include both alternative and traditional modalities)?
What has proven to be effective?
Are you taking any supplements? Please list the supplement and the reason for consuming it.
What would you like your health to be 30 days from now? How about 90 days from now?
What obstacles, challenges, and struggles do you face regarding diet and lifestyle?
What are 5 things you LOVE about your life?
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