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Creating Healthy Living
Queen it Up
Coaching
POWER Tips
About Me
My Faith
Queen it Up
Coaching
POWER Tips
About Me
My Faith
ONLY IF YOU ARE SERIOUS about losing your weight.., please fill out the Fact Find. The only way we can help you is if you are HONEST with your answers.... so don't hold back!
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Name
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First
Last
Please describe in detail what a typical BAD day of eating is like for you. BE COMPLETELY HONEST. Make sure to include the amounts of Soda, Juices and Alcohol that you consume as well and the costs associated with them.
On a Scale from 1-10, how Serious are you in Losing your Weight?
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Do you eat Breakfast?
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Yes
No
Breakfast
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Total $ Spent for Breakfast
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Midmorning Snacks
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Total $ for Snacks
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Lunch
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Total $ for Lunch
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Mid Afternoon Snacks
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Total $ for Mid Afternoon Snacks
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Dinner
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Total $ Spent on Dinner
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After Dinner Snacking
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Total $ Spent on Late Night Snacking
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TOTAL $ Spent Daily on Food & Drink
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What's your downfall when it comes to Food?
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What Health Concerns do have?
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Type II Diabetes
High Blood Pressure
Sleep Apnea
Skin Disorders
Depression
HIgh Cholesterol
Anxiety
Mood Swings
Cancer
Other
Any other useful information we should know before you start
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Submit