Online Wellness Evaluation Form

JUMP FITT 3.0 Wellness Evaluation Form
E-mail
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Marital Status
Do you have children? If so, how many?
GENDER
Age Range
Current Height (feet/inches)
Current Weight (pounds)
What would you like your Target Weight to be?

Wellness Priority
Rate (1-3) : 1 -VERY ACTIVE, 2 -MODERATELY ACTIVE, 3-NOT AT ALL ACTIVE
List YOUR Top 3 Fun Activities or Hobbies you enjoy the most.
What area of your body would you like to enhance?

Other
What is your biggest struggle when trying to LOSE/GAIN weight?
Where is your energy level, on a scale of 1 to 10? (1: Dragging / 10: Bouncing)
Do you take vitamins or any type of nutritional supplements currently?
Please list All Food and Medication Allergies. This is to ensure we have the correct plan of action for your Health, Nutrition, and Meal Plans only.
How many Glasses of Water do you drink daily

How much do you spend on groceries per week?
Do you eat out? How often? (Times/week)
What’s your Budget for getting started on your customized Nutrition Plan?

Name (1) TOP PRIORITY GOAL for each category to reach within the Next 30 Days: HEALTH, FITNESS, PERSONAL, BUSINESS/CAREER, SELF-CARE
Are you ok with One stream of Income, or open to the idea of Multiple streams of Income for you and your family?
How much Income Per Month would you like to bring home?

GOALS: Question, WHY? Really think about this thoroughly. Why do you want to accomplish these Goals and be as SPECIFIC, DETAILED, and REAL with yourself. How do you want your body to look and feel? Do you want more confidence? Do you want to be secure in your own body? Do you want overall satisfaction internally, as well as externally?
My Gratitude List - What are you most grateful for within this season of your life?
Name the Top 3 Fun Things You Love to do for yourself to Celebrate YOU?

My Products

20 DAY FITNESS CHALLENGE NUTRI PACK. 20 DAY FITNESS CHALLENGE NUTRITION PACKS INCLUDING PLANT BASED PROTEIN SHAKES, PLANT BASED HERBAL TEAS, AND PLANT BASED ENERGY BOOSTERS WITH BRAIN FUNCTION STIMULATIONS. (We also have Plant based Nutrition that is Non-Dairy, Vegan and Diabetic approved - please *special request with your Wellness Advisor)

20 DAY FITNESS CHALLENGE NUTRI PACK$55.00

20 DAY FITNESS CHALLENGE NUTRITION PACKS INCLUDING PLANT BASED PROTEIN SHAKES, PLANT BASED HERBAL TEAS, AND PLANT BASED ENERGY BOOSTERS WITH BRAIN FUNCTION STIMULATIONS. (We also have Plant based Nutrition that is Non-Dairy, Vegan and Diabetic approved - please *special request with your Wellness Advisor)

Quantity

3.0 FITNESS BOOTCAMP 23 - ADULT. 3.0 FITNESS BOOTCAMP 23 INCLUDES PROFESSIONAL COACHING, ADVISORY, AND MASSAGE THERAPY WITH OUR ZUMBA SESSIONS, FITNESS OBSTACLE COURSES, WELLNESS WORKSHOP, MASSAGE THERAPY SESSIONS FOR ADULTS AND YOUTH AGES 8 & UP!

3.0 FITNESS BOOTCAMP 23 - ADULT$25.00

3.0 FITNESS BOOTCAMP 23 INCLUDES PROFESSIONAL COACHING, ADVISORY, AND MASSAGE THERAPY WITH OUR ZUMBA SESSIONS, FITNESS OBSTACLE COURSES, WELLNESS WORKSHOP, MASSAGE THERAPY SESSIONS FOR ADULTS AND YOUTH AGES 8 & UP!

Quantity

3.0 FITNESS BOOTCAMP 23 - YOUTH. 3.0 FITNESS BOOTCAMP 23 INCLUDES PROFESSIONAL COACHING, ADVISORY, AND MASSAGE THERAPY WITH OUR ZUMBA SESSIONS, FITNESS OBSTACLE COURSES, WELLNESS WORKSHOP, MASSAGE THERAPY SESSIONS FOR ADULTS AND YOUTH AGES 8 & UP!

3.0 FITNESS BOOTCAMP 23 - YOUTH$15.00

3.0 FITNESS BOOTCAMP 23 INCLUDES PROFESSIONAL COACHING, ADVISORY, AND MASSAGE THERAPY WITH OUR ZUMBA SESSIONS, FITNESS OBSTACLE COURSES, WELLNESS WORKSHOP, MASSAGE THERAPY SESSIONS FOR ADULTS AND YOUTH AGES 8 & UP!

Quantity

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JUMP FITT 3.0 Wellness Evaluation Form

My Products

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