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As soon as you have submitted this form, be sure to send us an email at alwstaff@outlook.com. (Please be sure to answer every question, or we will not receive it.) We are excited for you to begin this wellness journey for a slimmer and more energetic you!

Name

Email Address

Phone

Address

City, State, Zip

Birthday Including Year

What is your current weight?

What is your goal weight?

What are your favorite foods and cravings?

How many hours of sleep do you get a night?

Do you sleep soundly?

How often do you move your bowels?

On a scale from 1 - 10, how do you rate yourself as far as being a healthy eater? (1 being low)

On a scale from 1 - 10, what is your energy level?

On a scale from 1 -10, what is your stress level?

On a scale from 1 - 10, what is your pain level?

Please describe your pain, if applicable.

Current Medications

Please check off the following health symptoms for Dr. Nelson's review. This will help her to customize your wellness program.

Would you like Dr. Nelson to recommend supplements to you based on your health test? *

Select an option

Please e-mail Jenna at alwstaff@outlook.com whenever you complete this form. If you do not answer all the required questions (*), the form submission will not work.

Select an option

Would you like Jenna to pray with you?

Select an option
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