Winning The Sugar Game Breakthrough Welcome

Welcome! It's Renee and this is your Health Intake Form for Winning The Sugar Game. Be as detailed as you can, it will give me a chance to get to know you better so we can focus our time on finding the right solutions for YOU. This is about finding what works best for your unique body. *All information will be kept strictly confidential.

Date*
MM slash DD slash YYYY
Name*
First Last
Email*
Phone
Birthdate*
Blood Type (if known)
Have you had periods of binge eating on sugar or carbs, or extreme dieting? [List any details and be as specific as you can.]*
Please share your current exercise habits*
Tell me about what you eat {not what you think I want to hear but a snap shot of your real reality each day}*
List any meds or supplements you are currently taking*
Explain your health, nutrition or body concerns in this moment*
Do you ever feel powerlessness, shame or isolation? If so, please explain. {Sugar addiction impacts us mentally, physically and emotionally. So dig deep and share yourself in any way you can.}
How do you handle stress or deal with challenging emotions?*
Is there anything else you want to share with me right now?

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Winning The Sugar Game Breakthrough Welcome