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Application form
  1. Application form Your Health Coach
  2. Name
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  3. Address
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  4. Zip code
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  5. City
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  6. Gender
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  7. Date of Birth
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  8. Telephone
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  9. E-mail
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  10. Occupancy
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  11. Please note down your personal goals (max 100 words)
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  12. Please note down any blocking factors or thoughts (max 100 words)
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  13. Questions

  14. 1. Do you smoke?
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  15. Yes: What?
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  16. When did you start?
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  17. How many a day?
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  18. 2. Do you drink alcohol?
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  19. Yes: What?
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  20. More than 2 servings per week?
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  21. How many servings at a time?
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  22. 3. Do you drink coffee?
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  23. Yes: How many per day?
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  24. How do you drink your coffee?
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  25. 4. Do you use sugar or sugar containing products like candy (bars), cookies, ice cream etc.?
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  26. Yes: what?
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  27. Daily?
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  28. 5. Do you use a microwave to cook or defrost food?
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  29. Yes: how many days a week?
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  30. 6. Do you prefer either a savory or a sweet taste?
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  31. 7. Do you crave sweets after a meal?
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  32. 8. Do you either feel cold or hot more often?
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  33. 9. Do you either prefer a cold or a warm drink?
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  34. 10. Can you skip breakfast easily?
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  35. 11. Can you skip snacks easily?
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  36. 12. Can you skip meals easily?
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  37. 13. Do you have an active lifestyle or do you work out?
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  38. Yes: Please comment
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  39. Yes: how many days a week?
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  40. 14. Are you in good health?
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  41. No: Please comment
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  42. 15. Are you seeing a health professional or specialist?
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  43. Yes: Please comment
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  44. 16. Do you have any allergies or food intolerances?
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  45. Yes: Please comment
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  46. 17: Do you use any medication or prescription drugs?
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  47. Yes: Please comment
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  48. 18: Do you use any food supplements or homeopathic supplements?
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  49. Yes: Please comment
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  50. 19. Do you recently experience any health complaints?
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  51. Yes: Please comment
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  52. 20. Did you experience any health complaints in the past?
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  53. Yes: Please comment
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  54. 21. Do you have any amalgam (silver fillings) in your teeth?
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  55. Yes: How many?
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  56. For how long?
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  57. 22. Have you had any root canal treatments in the past?
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  58. 23. Do you feel fit upon awakening?
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  59. 24. Can you fall asleep easily at night?
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  60. 25. Do you wake up at night to go to the bathroom to pee?
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  61. 26. Do you wake up at night several times a night?
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  62. 27. Do you have a bowel movement every day?
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  63. Yes: How many times a day?
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  64. No: Please comment
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  65. 28. What does your bowel movements look like?
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    Hard, cow, watery, small rabbit poop, with pieces, diarrhea, floats, sticky
  66. 29. What is the color of your bowel movements?
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    Dark brown, light brown, black, white, grey, green, yellow
  67. 30. What is the color of your urine?
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    Green, red, yellow, light yellow, no color

  68. If you are a woman, please answer these questions:
  69. 31. Are you pregnant or have given birth recently?
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  70. Yes: Please comment
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  71. 32. How would you describe your period?
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    Painful, more than 4 days, light, effortless, irregular, heavy bleedings
  72. 33. Do you experience hot flashes, night sweats or other menopausal symptoms?
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  73. Extra information
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  74. To be of even better service Your Health Coach offers the option to select the day, time and location you desire.
  75. Please indicate your preferred day, time and location.
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  76. 2. Time
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  77. 3. Location
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  78. I hereby declare that I have filled in this form truthfully and will not held Your Health Coach responsible when, through any cause or manner, damage is caused to myself or others. I agree with the costs of the treatment and consultation.
    I agree also with the fact that appointments can only be declined 24 hours in advance.

  79. I agree and understand the information above,
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