Author: Kristen

(801) 590-0876
715 E. 3900 S. #107
Salt Lake City, UT 84107

Name:
Address:
Phone:
Email:

1) Circle your problem areas.

2) Describe your current weight:
a) Under weight
b) Perfect weight
c) I would like to lose 5 - 25 lbs
d) I would like to lose more than 25 lbs

3) Describe your stress level:
0 = no stress 10 = very stressed
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