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Personal Health Advisor
Personal Health History - CONFIDENTIAL

This confidential personal health history information will be access ONLY by your Personal Health Advisor and utilized ONLY to assist you in obtaining your personal health goals.

* First Name:
* Last Name:
* Email:
* Phone Number:
  Cell Phone Number:
  Gender: Female:  Male:
  Date of Birth:
  Current Weight:
  Highest Weight:
  Weekday Waking Hour:
  Spouse/Significant Other:
  Current Exercise:
  Medical Conditions/Concerns:
  Why have you chosen now to make some changes:
  Goals for this program:
  Goals to reach in one year:
  On a scale of 1-10 (10 being that you won't let anything get in your way of success) how committed are you to this program?
  How Committed are you?

* Denotes a required field.


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