First Name
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Last Name
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Phone
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Marital Status
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Single
Married
Engaged
Living with Significant Other
Widow
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How Are You Motivated?
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Self-Motivated (I don't need much push)
Externally Motivated (I absolutely need a push)
My Goals Motivate Me (I want to live a long life)
My Fears Motivate Me (I don't want to die young)
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What is Your Age?
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How Much Do You Weigh?
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How Tall Are You?
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Please List Any Medical Conditions & Current Medications
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Please List Any Severe Injuries or Hospitalizations
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Please List Any Allergies
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Please Select All The Areas You Need Help With
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Water Intake (I don't drink enough water)
Exercise (I don't workout enough)
Sleep (I don't get enough quality sleep)
Food & Diet (I don't consistently eat healthy)
Mindset (I struggle to stay positive)
Life Purpose (I tend to lose direction in life)
Please Describe a Typical Day of Eating (Breakfast, Lunch, & Dinner)
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Please List Foods You Dislike
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Do You Eat Out Every Week? (Fast Food, Restaurants, etc.)
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Yes, more than 7 times per week
Yes, 3-7 per week
No, not really (2 or less times per week)
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How Much Do You Typically Spend Per Meal When You Eat Out?
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What Are Your Goals? Please List Three (Short Term, Mid Term, Long Term)
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