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RECHARGE
Health & Wellness

body recharging station

free consultation

General Wellness and Lifestyle

On a scale of 1-5, how would you rate your current overall wellness? (1=Poor, 5=Excellent
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5

Health History & Current Challenges

Are you currently experiencing any of the following? (Check all that apply)

Sleep

Is improving sleep one of your wellness priorities? (Yes/No)
Yes
No

Nutrition

How would you describe your current nutrition? (Check any that apply)
Are you interested in receiving nutrition tips or guidance as part of your wellness journey? (Yes/No)
Yes
No

Exercise & Activity

How active are you currently? (Check one)
I exercise regularly (3+ times per week)
I’m somewhat active but not consistent
I rarely exercise
Other
Are you looking to add more movement or fitness into your routine? (Yes/No)
Yes
No

Habits & Stress Levels

On a scale of 1-5, how would you rate your current stress levels? (1=Very Low, 5=Very High)
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5

Wellness Interests

Which types of therapies sound interesting to you? (Check all that apply—no pressure!)

Routine & Preferences

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