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Discovery Call Application
A Little About You
First Name
*
Last Name
*
Email
Email
*
Preferred Phone
*
*We only use this number to schedule your call – we respect your privacy
Health Concerns
What is your 3 main health complaints?
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How often does it bother you or your child ?
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How often does it bother you or your child ?
A
Every day
B
2-3 times per week
C
once per week
D
Once per month
How long has it been going on?
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How long has it been going on?
A
1-6 months
B
6 months to 1 year
C
1-3 years
D
Over 3 yrs
Date of Birth
*
Sex at birth
*
Potential Roadblocks
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Potential Roadblocks
A
Children
B
Partner
C
Time
D
Self (Motivation)
E
Money
F
Resources
G
Job
H
Fear
I
None
Your Journey So Far
What have you tried that worked or didn’t work?
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Describe current diet (be specific – meals & times)
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Supplements or medications you’re currently taking
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Your Vision
Where do you want your health or your child's health to be in 3–6 months?
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Biggest diet/lifestyle obstacles right now
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If we work together, what do you expect to achieve?
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What are 5 things you LOVE about your life or your child's life right now?
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On a scale of 1-10 how ready are you to invest in your health or your child's health right now?
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How Did You Find Me?
How did you find me?
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How did you find me?
Pinterest
Instagram
Facebook
Podcast
Websearch
Friend/Family
If Podcast or Referral – who should I thank?
Yes! Send me awesome health tips, tools & free resources!
*
Yes! Send me awesome health tips, tools & free resources!
Yes
No
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