Let's see where you are in your current Health and what your GOALS are!
Please take a moment to complete this voluntary assessment. It will help guide us in recommending the most accurate plan for you and your needs. If you decide that this program is the right fit for you, we can begin as soon as you are ready! I look forward to working with you and getting you to your goals!
Full Name
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𝔽𝕚𝕣𝕤𝕥 ℕ𝕒𝕞𝕖
𝕃𝕒𝕤𝕥 ℕ𝕒𝕞𝕖
Address
Street
Apt. #
City
State/Providence
Postal/Zip Code
Email
example@example.com
Phone Number
Date of Birth
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Month
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Day
Year
Date
Who/How did you hear about me or my 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)?
What health issues do you currently have that might require a more customized plan for your needs??
Please list any food allergies, medications, or supplements you are currently taking:
Body Landscape
What is your current weight?
How tall are you?
How would you describe your daily activity level?
Please Select
Sedentary
On your feet
Active
Weight
In a perfect world, if you could not fail, how many pounds would you want to lose?
Have you ever tried to lose weight before? If so what plan/program?
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?
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