8 Week Health and Wellness Challenge
Welcome! I am so happy you have decided to take this important step. In order for me to provide a more personalized experience, I would appreciate if you would answer a few questions about your current health and lifestyle. If you are uncomfortable sharing any of this information, please do not feel pressured and leave it blank. You will also find the agreement and liability waiver to sign and payment information. Once submitted, you will receive a welcome email with details regarding your next step.
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
On a scale of 1-10, one being unhealthy 10 being healthiest, how would you rate your current state of health?
Describe a typical day of food choices (breakfast, lunch, dinner, snacks)
Do you currently keep a food diary or log your meals?
Yes
No
Do you drink soda, sweetened teas, lemonade, specialty coffee drinks or other sugary beverages? If yes, about how many do you drink each day?
Do you drink Diet Soda or beverages?
How much coffee or caffeinated tea do you drink each day?
How often do you drink alcohol?
Do you smoke or use any other recreational drug?
What are your personal Health and Wellness Goals?
Are there any health concerns you feel I should be aware of? If yes, please explain
By signing here, I acknowledge that I have read and agree with the Client Agreement and Release of Liability
*
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8 Week Fall Health and Wellness Challenge
$
129.00
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Card Expiration
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