THE SOUTHERN·ISH MAMA
POSTPARTUM SLIMDOWN
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Health Questionnaire
*
Indicates required field
Name:
*
First
Last
Email:
*
Phone Number:
*
AGE:
*
HEIGHT:
*
4'10"
4'11"
5'
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'
6'1"
6'2"
6'3"
OTHER
CURRENT WEIGHT (LBS.):
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PRE-PREGNANCY WEIGHT (LBS.):
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Have you lost a significant amount of weight in the last 6 months?
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Yes
No
ARE YOU PREGNANT?
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Yes
No
When did you give birth to your last child?
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Less than a month ago
2 to 3 months ago
4 to 6 months ago
7 to 9 months ago
10 to 12 months ago
1 to 1.5 years ago
2 to 3 years ago
More than 4 years ago
I don't have kids!
Are you breastfeeding?
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Yes
No
Please specify when you stopped breastfeeding:
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Are you on any anticoagulant or antiplatelet medications?
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Yes
No
If yes, please list:
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List of current medications and/or supplements:
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List of any preexisting health conditions (depression, anxiety, etc.):
*
List any allergies, intolerances, or sensitives to foods and/or medications?
*
What are you weight loss goals? Be specific.
*
Submit
POSTPARTUM SLIMDOWN
Blog
Motherhood
Pregnancy
Baby & Child
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Lifestyle
About
About
Contact
Contact
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