The Hormone Reset Plan
Client Intake Questionnaire
Please fill out the below questionnaire to help me help you better
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Name
Email
Date of birth
Do you have any diagnosed medical conditions? Please list
Are you currently taking any medication? Please list
Do you have any allergies or intolerances?
What health goal would you like to achieve?
How motivated on a scale of 1-10 are you to do something about this right now?
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10
What obstacles and challenges have stopped you from doing this in the past?
Is there anything I should know about you to help you get the results you want?
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