Nutritious Family.com
From My Healthy Home to Yours


Healthy Life and Nutrition Coaching
Cooking Classes
Personal Chef Services
 Non-Toxic Products

 

Please fill out the form below and submit for review.  Someone will contact you within 48 hours.

Questionaire

This questionare is required to be considered for coaching.  All information is completely confidential.

First name:
Last name:
Evening phone number:
Daytime phone number:
Email Address:
City you currently live in:
Do you eat breakfast?:
Do you feel tired and worn down by lunch time?:
How many glasses of water do you typically drink per day?:
How many children do you have currently living at home?:
Are you currently pregnant?:
How many days/week do you drink alcohol?:
Do you smoke cigarettes?:
Are you currently taking prescription medications?:
How many hours of sleep do you get daily?:
Are you addicted to sugar?:
Are you addicted to caffeine?:
Would you say your current health and eating habits are great, fair, or poor?:
What is your main reason for wanting to make a change and learn new habits?:
On a scale of 1-10 How committed are you to changing your current eating/health habits?:
Additional Comments:
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