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National Nutrition Month Giveaway

First name

Last name

Email

Instagram handle

What program are you most interested in?

Have you worked previously with a registered dietitian?

Yes

No

If yes, what was your experience like?

What are your top 2 health/wellness goals right now?

Have you tried traditional/fad diets before? If so, please list below what you have tried in the past and what the outcome was.

Do you have a previous diagnosis of an Eating Disorder (anorexia nervosa, bulimia, ARFID, etc.)?

Yes

No

If yes, please explain:

Do you consider yourself to be an emotional eater, stress eater, or binge eater?

Yes

No

Not quite sure

On a scale of 1-10, how ready are you to commit to changing your relationship with food and body forever?