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Work With TBalance
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Cart
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Work With TBalance
Courses
Podcasts
Testimonials
Contact
PERSONAL INFORMATION
Name
*
First Name
Last Name
Telephone / Email
*
Date of Birth
*
Height & Current Weight
Would you like your weight to be different?
SOCIAL INFORMATION
Relationship Status
Where do you currently live?
Do you have children?
Occupation
How many hours do you work per week?
HEALTH INFORMATION
Please list your main health concerns
Any other concerns and/or goals?
At what point did you feel best in your life?
Have you had any serious illnesses / hospitalisations / injuries?
How is your sleep?
How many hours do you get?
Do you wake up at night?
Do you experience yeast infections / urinary tract infections? Y /
MEDICAL INFORMATION
Do you take any supplements or medications? Please list
Have you had in the past / do you have healing, therapy or any other kind of help? Please list
Do you exercise? If so, how often?
FOOD INFORMATION
What percentage of your food is home cooked?
Do you crave sugar, coffee, cigarettes or have any major addictions?
Please list what you eat for breakfast, lunch, supper & snacks
Is there anything else you’d like to share?
Thank you!
