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Let's Nutrition Health Assessment Form
Name:
Date of Birth:
 / 
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Age:
Height:
Weight:
Gender
E-mail:
Home Phone:
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Cell Phone:
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Work Phone:
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Address:
How did you hear about us?
Who should we thank for referring you?
Who encouraged you to lose weight?
How Important to you is to lose weight?
What important reason, special occasion or goal date do you have to lose weight?
How many pounds would you like to lose?
How fast do you want to lose the weight?
Have you ever attended any other weight reduction centers, if so which ones?
what kind of diet have you tried on your own?
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