First Name
Last Name
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On a scale of 1-10, how would you rate your current health/well-being?
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9
10
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What specific health challenges are you currently experiencing?
Have you received a formal diagnosis, or is it a self-identified experience?
Formal Diagnosis
Self-identified
Other
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Do you have a history of antibiotics?
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No
Not sure
Are you currently on any medication?
What have you tried so far to address these challenges?
Where would you like to be in your health journey one year from now?
What do you believe is holding you back from achieving these goals?
What support do you feel would be most beneficial for your journey?
How would achieving your health goals impact other areas of your life?
What would it mean to you personally to overcome your current health challenges?
Is there anything else you'd like me to know before our call?
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