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Client Consultation Form

Please fill out the following form, to the best of your ability, in order to continue with your consultation. If you have any further question contact me with the button below.

Health & Wellness Declaration

This form is made up of 5 sections and takes approximately 5-10 mins to complete.

Gender
Preferred Pronoun's
Have you been hospitalized in the last 12 months?
Are you suffering from a medical condition, illness, or injury?
How many times a week do you exercise / move with intensity?
How much time would you be willing to allocate yourself for a morning routine?
How much time would you be willing to allocate for an evening routine?
Do you follow a specific eating style or diet?
Do you eat greens daily?
Do you drink water daily?
Do you have caffeinated beverage in the first hour of waking up?
Do you take any supplements?
On average how many hours of sleep do you get a night?
Do you have any issues staying asleep through the night?
How would you rate your sleep quality?
How Stressful do you consider your job to be?
Do you watch, listen to, or read the news daily?
Is there anything else you believe you use to distract yourself from, or distract yourself from, or to conceal your stress and or anxiety?
How often do you feel negative emotions arise out of nowhere?
How much time do you spend scrolling on social media?

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©2022 by Charley Dickins.

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