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Jan Cloutier - Wellness Coach
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Wellness Intake Form
Tell Me a Little Bit about Yourself
Are you taking any medications?
*
Yes
No
If yes, please list name and use:
*
Mercury
Mars
Jupiter
Radio button 1
Radio button 2
How many continents are there?
5
6
7
Who was the first man to go into space?
Neil Armstrong
Yuri Gagarin
Buzz Aldrin
Where is Budapest?
Hungary
Spain
Portugal
Which of these is a prime number?
1
17
21
4
Submit
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