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Health Consultation Questionnaire
peace & good Greets!

please fill out this form to the best of your ability so I can best serve you for your 1:1 cooking & healing call and/or in person session!

30-min phone call sessions are $75.
cost of in-person sessions vary depending on your location.

if your needs are outside of my realms of understanding, I reserve the right to cancel your booking and offer you a full refund. 

grateful to play a role on your healing journey.

- Chef Danielle Henry
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First Name *
Last Name *
What is your age? *
What is your weight? *
What is your date of birth?
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What are your health challenges? *
When at work what kind of environment are you in? Are you always on a computer or a phone? Do you have to sit or are you standing? Give us a clear picture that captures your day. *
If money wasn't a variable in your life, what would you spend your time doing? *
How many hours of sleep do you get each night and how well do you sleep? *
Are there any chronic or acute pains/symptoms in your body? *
Do you have any Allergies or Sensitivities? *
Please list all supplementation or medication taken and quantity consumed. *
What are your health goals? *
How many hours a week do you do physical activity? *
What foods did you enjoy most as a child? *
What are your favorite foods now, as an adult? *
What foods do you stay away from?
What foods do you consume during a typical day? Include 2 days. Please use brand names for packaged foods. *
How much of your weekly food intake is raw? Calculate based on percentage. *
Do you like smoothies? *
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