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Register for a Complimentary Session
Register for a Complimentary Session
sa360
2022-03-26T15:20:01-05:00
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*
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Name
*
First
Last
Address
*
Street Address
Bldg & Apt # (if not a house/condo)
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Phone
*
Which 3 matter most to you:
*
Nutrition
Metal Toxicity
Speed
Flavor
Cost
Fat/Calories
How important is health on scale of 1-10 (1 Low - 10 High)
*
Please enter a number from
0
to
10
.
Most meals are cooked
*
At Home
By Restaurants (take out and/or sit down)
Are you
*
Married
Single
Do you have children?
Yes
No
Your age range?
*
Under 21
21-35
36-50
50-65
66+
Are you
*
Employed
Retired
Seeking PT or FT income
If your name is drawn, which days are best?
Sun
Mon
Tues
Wed
Thurs
Fri
Sat
Family History Health Concerns
Father's History Health Concerns
Digestive issues
Auto-immune issues
Neurological (autism, alzheimers, etc)
Diabetes
Cancer
Heart Disease
High Blood Pressure
Weight Concerns
Unknown
Mother's History Health Concerns
Digestive issues
Auto-immune issues
Neurological (autism, alzheimers, etc)
Diabetes
Cancer
Heart Disease
High Blood Pressure
Weight Concerns
Unknown
Do you prefer
In-person Meal
Virtual via Zoom
Either
Do you prefer
Lunch
Dinner
Either
Do you own or rent a house?
Yes
No, I’m in an apartment
I live with family
Please list any food restrictions or diet followed:
Dairy
Eggs
Gluten
Corn
Vegetarian
Vegan
Other
Other
*
Email
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