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Personal Health & Wellness Form

Thanks for signing up for a Health & Wellness Consultation with me. I'm looking forward to speaking with you!

 

Before we meet, please complete this Personal Health & Wellness Form below before your scheduled session. It will provide me with some basic background information on you, allowing us to dive a little deeper during our 40 minutes together. With the exception of the information marked with an asterisk (*), you only need to respond to the questions you feel comfortable answering. All information is secure and will be kept confidential between you and me.

 

If you would prefer to fill this out by hand, you can download it here and email the completed form back to me before your Health and Wellness Consultation session.

Personal Information

Social Information

Health Information

Diet Information

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Disclaimer: The information on this website is not intended to diagnose, treat, cure or prevent any disease. We present these stories, articles, website links, other documents, etc. for informational and educational purposes only and do not endorse or necessarily agree with their contents. The information contained herein is not intended to replace a one-on-one relationship with a doctor or qualified healthcare professional. We are not doctors and make no claims for any cures, either stated or implied, and assume no liability for others’ experimentation. We merely relay information from qualified sources for the perusal of the free citizens of the world. Connect4Hope, LLC encourages you to make your own healthcare decisions based on your judgment and research in partnership with a qualified healthcare professional. These statements have not been evaluated by the US Food and Drug Administration (FDA). 

 

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