Thank you for filling out my Survey!
Best number to reach you on
How did you hear about me or our programs?
What would you like to accomplish most with your health right now (lose weight, sleep better, less stress, come off medications, more energy, etc)?
Please describe WHY you are interested in getting healthy. (What is your main motivation? Relationships, activities, how you feel, etc)
Are you pregnant?
Are you nursing?
If yes, how old is your baby?
Do you have the following?
Diabetes - Type 1
Diabetes - Type 2
High Blood Pressure
Is there any food allergies or other allergies that I should be aware of?
Are you taking any medications for:
High Blood Pressure
Please list any medications or supplements you are currently taking:
How many hours of sleep do you typically get?
What time do you typically wake up?
How is your quality of sleep and do you wake up feeling rested?
How much water do you drink each day?
Do you consume any other beverages?
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
Do you currently exercise? If so, how many times a week?
What physical / exercise activities do you participate in?
How would you describe your daily activity level?
On your feet
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Are there any other stressors in your life?
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
Current Weight: (if you want to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who would like to get healthy with you?
Street Address Line 2
State / Province
Postal / Zip Code
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