Metabolic Health Assessment with Rebecca Coltrane

It's Time for a Metabolic Reset

These questions help me understand what brings you here and how this program will be a strong fit for you.
Tell me about you
First and Last Name
Email
example@example.com
Phone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital status

Other
What do you do for work?
On a scale of 1-10, how much do you enjoy what you do?

1

2

3

4

5

6

7

8

9

10

1 is I hate it, 10 is Very happy
What does a typical day of eating look like for you? (This includes beverages - Starbucks, alcohol, anything that goes in your mouth. Please include when you have your first meal of the day and how many times you eat throughout the day.)
On average, how much do you spend on food and beverage each day?
Current Health Snapshot
Age
Height
Weight
Do any of these apply to you? (select all that apply)

Other
Are you pregnant or nursing?
On a scale of 1 to 10, how would you rate your overall emotional well-being right now?

1

2

3

4

5

6

7

8

9

10

1 is Thriving, 10 is SOS
Describe your most common sources of worry or stress. How do they affect your daily life?
How many hours of sleep do you get on average each night?
How would you rate the quality of your sleep on a scale of 1 to 10?

1

2

3

4

5

6

7

8

9

10

1 is Horrible, 10 is Excellent
On a scale 1-10, how would you rate your energy level

1

2

3

4

5

6

7

8

9

10

1 is Thriving, 10 is SOS
How much water do you drink daily?
How much alcohol/soda/sweet tea weekly or monthly do you consume? What are your drinks of choice?
Do you exercise? Describe the type and intensity of the healthy motion you typically do. (If you don't currently move your body, that's OK! If you are currently incorporating healthy motion into your week, please let me know how many times per week.)
Do you have any food allergies or medical conditions or current medications that I should know about?
Your Vision + Your Why
I would love to hear what you would like to accomplish with your health. Please select all that apply

Other
What is your main motivation for wanting to make changes to your health? (Relationships, activities, how you will feel, confidence, etc.)
Your Current Metabolic Symptoms
Which of these describe you right now?

Other
Are You Ready for a True Metabolic Reset?
If there was a proven path that burns fat, protects 98% of your lean muscle, and reverses metabolic dysfunction, how open are you to following it exactly as designed?
Are you prepared to invest time, energy, and money into your health if the plan fits you?
How soon would you want to start?
COMMITMENT LEVEL: On a scale of 1-10, how committed are you to making lasting changes in your health?

1

2

3

4

5

6

7

8

9

10

1 is Not so sure, 10 is Let's do this!
Is there anyone else in your life who would like to get healthy with you? It is so much fun to do this with a friend of family member and surround yourself with a healthy community!
Have you done Optavia before and who was your coach? What did or did not work with that connection?
Anything else you want me to know?
| Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.
This program has transformed thousands of lives (including mine!) through science-backed methods and proven results.

The formula is simple: when you commit to the process, results follow.

Here's the beautiful truth: YOU are the author of your success story. While I'll be here guiding you every step of the way, your commitment lights the path.

Yes, change can feel challenging - those old habits didn't form overnight! But imagine the joy of finally taking control of your health, feeling energized in your daily life, and showing up as your best self for those you love.

In 2020, I stood exactly where you are now. Uncertain but hopeful. Ready for change but nervous about the journey. Today, I can tell you it was the best decision I ever made - not just for me, but for my whole family.

Your time is now. Your transformation is possible. And your future self will thank you for this moment.
Should be Empty:

It's Time for a Metabolic Reset

Tell me about you

Current Health Snapshot

Your Vision + Your Why

Your Current Metabolic Symptoms

Are You Ready for a True Metabolic Reset?