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Wellbeing Nutrition, LLC

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Nutrition and Mindfulness Self Assessment

Please fill out the following form to help us understand your physical condition.

I drink at least 8 cups of water daily. *

Yes

I don’t drink excess alcoholic beverages. (More 1 drink for women and 2 drinks for men) daily. *

Yes

I eat Greek Yogurt or other probiotic rich foods daily. *

Yes

I get physical activity for at least 30 minutes daily. *

Yes

I get at least 7 to 8 hours sleep each night. *

Yes

I generally feel grateful and happy. *

Yes

I’m generally a patient person. *

Yes

I have healthy blood pressure *

Yes

I don’t experience headaches, feeling of fainting, worry, dizziness, heart palpitations *

Yes

First Name, Last Name, and Email

Thanks for submitting!

MIND AND BODY SELF ASSESSMENT

Please fill out the following form to help us understand your physical condition.

I drink at least 8 cups of water daily. *

Yes

I don’t drink excess alcoholic beverages. (More 1 drink for women and 2 drinks for men) daily. *

Yes

I eat Greek Yogurt or other probiotic rich foods daily. *

Yes

I get physical activity for at least 30 minutes daily. *

Yes

I get at least 7 to 8 hours sleep each night. *

Yes

I generally feel grateful and happy. *

Yes

I’m generally a patient person. *

Yes

I have healthy blood pressure *

Yes

I don’t experience headaches, feeling of fainting, worry, dizziness, heart palpitations *

Yes

Please submit your name and email to receive results!

Thanks for submitting!

Disclaimer

This Self-Risk assessment is not intended to diagnose any conditions. Your physician is the only one that can diagnose
health conditions.
This self-assessment is for the purpose of identifying which nutrition and mindfulness approach would be most effective
to helping you achieve optimal health and wellbeing.

Wellbeing Nutrition, L.L.C.

Evangelina DiSpirito, RD, LDN, E-RYT

Email: info@wellbeingnutrition.net

Phone: (678)720-8507

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