21 Day Reset and Refresh Programme health form

Welcome to Your Reset and Refresh Journey!

Congratulations on taking this bold step toward revitalising your health and well-being. This 21-day mini detox programme is all about empowering you to:

✤ Quit sugar and alcohol for 21 days

✤ Walk a minimum of 10,000 steps daily

✤ Drink at least 2 litres of water a day

✤ Start your morning with protein-packed breakfasts

✤ Cut back to one cup of tea or coffee per day

Over the next three weeks, you’ll reset your dietary choices, rebalance your energy, and create habits that support a healthier, more vibrant you.

What's Next?

To ensure I can fully support you on this journey, I need to know a little more about your goals and current lifestyle.

💬 Please complete the short questionnaire below.
This will help me tailor the guidance and support to your needs, so you can get the most from the programme.

Prepare for the Journey: Once submitted, keep an eye on your email for further details, including your guidance sheet and access to our private WhatsApp group.

I'm excited to support you on this journey toward renewed energy, balance, and vitality.

Let's do this together!

Valerie x

 

 

Reset        

Refresh

Starts 20th January 2025

 

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Registration Form

Please tick yes or no to the following questions

1. Have you ever been diagnosed with a heart problem or have you ever had a heart attack? 

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2. Do you feel pain in your chest area or have any difficulty breathing?

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3. Do you suffer from dizzy spells or have you ever lost consciousness?

 

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4. Are you currently on any form of medication or under the care of a doctor for any reason?

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5. Are you pregnant or have you had a child in the last year?

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6. Have you experienced or are you currently undergoing the menopause?

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7. Do you have or do you have any family history of any of the following:

✤  Strokes

✤  High blood pressure

✤  Diabetes

✤  High cholesterol level

✤  Asthma

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8. Have you undergone any major surgery in the last year?

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9. Have you had any serious illnesses in the last year?

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10. Do you have any of the following:

✤  Thyroid problems

✤  Arthritis

✤  Hernia

✤  Anaemia

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11. Do you smoke? If so, how many cigarettes per day?

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12. Is there any reason that you are aware of that you should not undertake this Reset and Refresh Programme

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If you have answered YES to any of the questions, please outline in more detail below, the nature of the complaint or condition.

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I agree to participate in the Reset and Refresh programme and I also understand that this programme must be completed in conjunction with making my own lifestyle adjustments. I understand that completing the programme is entirely at my own risk, and should I wish to stop I am at liberty to do so.

 

The information I have provided is to the best of my knowledge complete and accurate.

Please sign and date.

 

 

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