Weight Loss Program with Indian Food Recipes
Vegetarian Food Recipes
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Please fill out this short health survey for a free consultation. I will contact you shortly. Please be honest and thorough as this will help me provide you with the best possible advice. All information is completely confidential and will never be seen by anyone but myself. Please also rest assured that you will not be under any obligation by completing this survey.

General Information
First Name*
Last Name*
Address 1
Address 2
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Telephone*
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What is your gender?
What is your age group?
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Health Information
What is your height? feet inches
What is your current body weight ? pounds
How much weight do you want to lose? pounds
How many meals do you eat per day?
How often do you eat out?
How many glasses of water do your drink per day?
Where is your energy level, on scale of 1 to 10?
Are you currently taking any prescription medications?
If yes, for what health problem?
Do you take vitamins or any type of nutritional supplement?
Do you have problem with snacking?
What is your weakness?
Where do you carry most of your unwanted weight?
Does your body retain water?
List 3 or more things about your health you would change?  












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