Please take your time and answer
the questions below.
1. On a scale of 1 to 10 (10 being the best) where/how would you rate your level of health?
1 2 3 4 5 6 7 8 9 10
2. According to the previous question … What would you like to change about your daily routine? (be specific)
3. When and how will you do this?
Date___________
Plan of Action:
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