First Name *

Last Name *

Email *

Age *

Your Gender *

Your Location *

Any Current Illness or Treatments? *

Any Past illness? *

What Medications Are You Currently Taking? *

How Many Hours a Night Do You Currently Sleep? *

Do You Take Daytime Naps? *

How Often Do You Exercise? *

How Many Days Per Week Do You Eat Homemade Meals? *

Stress Level 1-10 (1 is low and 10 is very high) *

1

2

3

4

5

6

7

8

9

10

How Do You Currently Manage Your Stress? *

Are You Ready to Invest in Yourself? *

Are You Open-Minded? *

Are You Ready to Make Small but Powerful Changes to Feel Better? *

Anything Else I Should Know About You? *

What is the #1 Most Important Thing You Want to Improve Today? *

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