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Doterra
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About the Founder and Coach
Menu of Services
Products
Gift Certificate
Trivita
Doterra
Wellness Community
Contact
Intake Form
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Do you have allergies to lotions, candles, oils?
Yes
No
If yes, what are they:
Do you have any injuries that we should know about?
Yes
No
If yes, what are they:
Type of body work that you prefer:
Light Pressure
Medium Pressure
Deep Pressure
How would you rate your overall health if 10 is great?
1
2
3
4
5
6
7
8
9
10
Do you eat three meals a day?
Yes
No
If no, describe a day of your typical eating habits:
Do you smoke?
Yes
No
Do you drink any caffeinated drinks or alcohol?
Yes
No
If yes, for either or both. How much of either per day or week and what do you think?
How much water do you drink daily?
What is presently causing you to go into stress mode?
If you are a parent, what is your biggest parenting challenge?
What areas of your health would you like to improve?
Do you work out?
Yes
No
If you, how often?
Would you say so far you are more into drugs to assist with health issues or natural healing and preventative healing, etc?
Drugs for Health Care
Natural Preventative Health Care
What are you currently using for your skin care?
Are you satisfied with the results?
Yes
No
Are you interested in learning more about new ways of improving your health, skin, life balance and happiness?
Yes
No
Wellness Workshops & Classes
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