Name *

First Name

Last Name

Phone

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Movement (1-5)

*A score of 5 would be considered intentional movement everyday. A score of 1 would be no intentional movement or lack of awareness/need guidance.

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Nutrition (1-5)

*A score of 5 would be eating real, one ingredient foods (for the most part) and eating your meals in a slow, peaceful and mindful environment. A score of 1 would be eating mainly processed foods and little to no awareness around food or your environment (screens, busy/on the move, rushing).

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Hydration (1-5)

*A score of 5 would mean drinking half your bodyweight in ounces of water per day, everyday and including some sort of salts/electrolytes. A score of 1 would be little to no water and feeling dehydrated, low energy and lethargic.

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Sleep (1-5)

*A score of 5 is sleeping 7-8 hours per night uninterrupted, every night and feeling energetic when waking. A score of 1 would be less than 7 hours of sleep with frequent/consistent interruptions and feeling unrested when waking and tired throughout the day.

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Stress (1-5)

*A score of 5 means feeling centered, present, mindful and content most of the time. A score of 1 means feeling uneasy, anxious, swings of emotions, and tense most of the time.

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Rhythm (1-5)

*A score of 5 means sleeping/waking, eating meals, and moving/exercising at the same time everyday, while getting sunlight every morning. A score of 1 would mean no consistency in sleep, meal timing, or movement. Your job/career can impact this as well if you travel a lot or are a night shift worker.

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