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If you are interested in signing up for our bi-monthly wellness/nutrition tips and musings, please add your e-mail. Twice a month we send our new product lists, recipes, and/or wellness reflections.

 

1003 Diamond Ave
South Pasadena, CA, 91030
United States

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Fit-Fax Plus: Wellness Consult Form

Fit-Fax Plus Intake Form

 
Name *
Name
(This will forever remain private and secure)
BACKGROUND
Please include dosages. If you are on birth control, please note what type.
Any family Type 2 diabetes, high blood pressure, cancer, metabolic syndrome, etc.?
Please note any bouts of situational depression or anxiety.
Please note any recent changes in period duration, frequency, intensity, etc.
1) Activity/movement
Please note any sports or activities you enjoy.
Please note any broken bones, surgeries, torn tendons, etc.
2) Body image/self-esteem
3) Relationship with food
OVERALL WELLNESS INTENTIONS
Please note any chronic pain, digestion issues, headaches, high blood pressure, pre-diabetes, etc.
SUPPLEMENTS
Please include dosages.
1) Nutrition
2) Lifestyle
For example: 5 am wake Coffee 6-7 Am Run Shower Drive 9-10 am @ Work at 10 am 10 am breakfast 2 pm Lunch 4 pm Grab Snacks 6-7 pm Drive Home 8 pm Dinner 11 pm Bed
Please check the following kitchen items you own/use:
Please check the following skills you have practiced:
ADDITIONAL WELLNESS QUESTIONS
ACCOUNTABILITY