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Have you ever had anyone hold you accountable to your nutrition related goals? Required
Do you have experience with Antibiotic use? Required
Are you on birth control? Required
Are there any foods that you avoid? Required
Do you currently take any vitamin/mineral supplements? Required
Have you ever tried eliminating certain foods or food groups from your intake? Required
What is your overall level of exercise? Required
How often do you dine out weekly? Required
Your meal most often eaten out: Required
What time of the day do you feel most hungry? Required
How many caffeinated beverages do you consume daily? Required
Do you smoke tobacco products? Required
How many days do you consume alcohol? Required
How would you rate your quality of sleep? Required
Do you have troubles falling asleep? Required
How would you rate your level of stress? Required
Have you ever been diagnosed with an eating disorder? Required
Check all that apply to you: Required
I usually eat breakfast around: Required
I usually eat lunch around: Required
I usually eat dinner around: Required
What is your present level of commitment to change any underlying causes of your signs and symptoms which relate to your lifestyle? (rate from 0 to 10 with a 10 = 100% committed) Required
Acknowledgment of Financial Policy - I understand the following policy: I am responsible for the total payment of my program, including a program payment plan, after the first counseling session is completed. Subscription cancellations or program holds are not permitted. Required

Address

Phone

585.217.6989

21 Goodway Drive

Henrietta, NY 14628

Email

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