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Wellness Check-In Form
View Past Submissions
Title of Check-In Entry
Name
How has your sleep quality been in the past 1 - 2 months?Â
*
Not Great
Fine
Excellent
Have you been able to follow the food & lifestyle suggestions that we discussed?
*
Not Very Well
Somewhat
Yes
Have you been taking the suggested herbs or formulations?Â
*
No
Yes
N/A, I did not receive herbs/formulation suggestions
How about digestion?
*
Not very good
Fluctuates
Digestion is great
Are you currently having difficulty with? What are the challenges?
*
Suggestions were too complex
Making time for myself
Access to food / cooking / ingredients
Life feels too busy
Other
Do you have any current imbalances that you would like to address / or are having a hard time managing?
*
Skin
Sinus / Congestion
Allergies
Weight management
Mind care
Joint / Muscle Pain
Not at the moment, I am feeling great!
What new, positive shifts have you observed in your life due to the changes you have been making?
N/A
What new, positive shifts have you observed in your life due to the changes you have been making?
Notes about any previous questions or other comments:
N/A
Notes about any previous questions or other comments..
Would you like me to follow up with you?
*
Yes
No, I will reach out on my own
Submit
Your content has been submitted
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