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Apply to Work with Dr. Suzanne

Determine whether the Fasting Solution coaching programs are a right fit for you!

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Question 1 of 14

How did you hear about the Fastin Solution? If you were referred, who referred you here?

Question 2 of 14

How old are you?

Question 3 of 14

How long have you been overweight?

Question 4 of 14

How much weight would you like to lose?

Question 5 of 14

Have you tried to lose weight before? What have you tried? Were you successful?

Question 6 of 14

Do you have emotional connections to food?

Question 7 of 14

Do you have any additional health concerns? (digestive disorders, chronic pains, reproductive issues, autoimmune disorders, headaches/migraines, mood disorders, anxiety, depression, past surgeries etc...)

Question 8 of 14

On a scale of 1 to 10 how would you rate your stress levels? If high, please explain:

Question 9 of 14

What is your quality/legnth of sleep like?

Question 10 of 14

Anything else that you would like me to know about you?

Question 11 of 14

If you should be a candidate for one of Dr. Suzanne's customized weight loss coaching programs, do you feel you would be more successful in a group coaching environment or working with Dr. Suzanne in a one on one coaching program?

A

Group Coaching Environment

B

I prefer and need one on one coaching/accountability to be successful

C

Either would work for me

D

Not sure, would like to discuss

Question 12 of 14

What is the BEST day/times for your call with Dr. Suzanne?

Question 13 of 14

What is your cell phone number?

Question 14 of 14

Please type your name below to acknowledge the following: I understand that Dr. Suzanne is a trained doctor of chiropractic with additional and extensive nutrition/ fasting studies. Anything you discuss during the consult is for informational purposes only and is not in lieu of any medical advice given by you primary care doctor. 

 

 

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