Name
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First Name
Last Name
Email
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Phone
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(###)
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Any prior health conditions or medications taking?
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1) Work-Life Balance
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How often do you feel like you have enough time for personal activities outside of work?
2) Work-Life Balance
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On a typical workday, how many hours do you spend on work-related tasks, including emails and calls?
7) Work-Life Balance
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What is one change you wish you could make to improve your work-life balance?
10) Current Health Status
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Do you experience any of the following common ailments regularly? (Select all that apply)
13) Current Health Status
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What is your biggest current health concern?
15) Stress Levels
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What are your main sources of stress? (Select all that apply)
16) Stress Levels
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How does stress usually manifest for you? (Select all that apply)
20) Stress Levels
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What is one thing that would help lower your stress?
26) Nutritional Health
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Do you experience any of the following food-related issues? (Select all that apply)
31) Physical Health
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Do you have any of the following mobility issues? (Select all that apply)
35) Physical Health
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What is one fitness goal you’d like to achieve?
40) Mental Health
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How do you usually cope with stress? (Select all that apply)
48) Life Satisfaction
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What is one thing that would make your life significantly better right now?
