What are your goals? - Legacy of Health and Wellness

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What are your wellness goals?
Congratulations, you have taken the first step to say YES to your health! We would love to help you create a legacy of health and wellness. Please fill out the survey below and we will be in touch with you on the next steps to better health.

Debra & Michael Hermsmeier
Date

MonthDayYear
Today's Date
First Name

0/20
Last Name

0/20
Email
example@example.com
City, State
Area Code
Format: (000) .
Phone Number
Format: 000-0000.
Date of Birth

MonthDayYear
How did you hear about us?
If you were referred, name of the person who referred you. Or Facebook, Instagram, Chamber, Event, etc.
Preferred contact method
Background
Check ALL that apply:
If nursing, how old is your baby?
Are you taking other medications or have other medical conditions that could influence which program we choose?
Are there any dietary restrictions you currently utilize? Please specify if you have a diagnosed food allergy.

0/160
Where You Are Now
Describe where you are in your health now. This can include your weight, nutrition, sleep, stress, mindset, and energy.
Where would you like to be in your health?
Describe WHY you are interested in getting healthy. What is your main motivation: relationships, activities, how you feel or look?
What are some things you will enjoy when you are healthier? (Ex: walking, confident in a bathing suit, play on the floor with kids or grandkids...)
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?
Sleep
How many hours of sleep do you typically get?
What time do you typically wake up?
How is your quality of sleep? Do you wake up feeling rested?
Hydration
How much water do you drink per day?
How many cups of coffee or tea do you drink per day?
How much soda do you drink per day?
How many energy drinks?
How much alcohol?
Movement
How would you rate your energy level? (on a scale of 1-10)
How many times a week do you exercise?
What physical activities do you participate in?
Are there things you can't do that you would like to be able to?
Mind
How would you rate your stress level? (on a scale of 1-10)
What do you do for work?
How much do you enjoy what you do?
When and where was your last vacation?
What other stressors are in your life?
Eating Habits
How many meals per day do you eat?
When do you eat your first meal?
When do you eat your last meal?
Do you snack between meals? What kind of snacks?
How many times a week do you eat out?
Weight
Current Weight
Goal Weight
Age
Height
GENDER
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?
Surroundings
How healthy would you rate your surroundings? (on a scale of 1-10)
Do you have healthy & active friends, a supportive family, keep junk food in the house, etc.?
Is there anyone in your life who would like to get healthy with you? $25 gift for each referral. Feel free to share this form with your friends and family.
Medically Assisted Weight Loss
Are you currently on a GLP1 medication for medically-supported weight loss?
If you have ever before or currently use medically-supported weight loss, please describe your experience:
Have you had gastric bypass surgery, or are you contemplating it? Describe any limitations in your appetite from the surgery:
Optavia has partnered with LifeMD to provide options for medically-supported weight loss. Our goal is to provide the medical tools people need to be successful among with the education, accountability, community, and convenience they need to create lifelong habits.

Working with LifeMD includes contact with a nurse practitioner for your prescription, weight loss guidance, and daily and urgent care support. Pairing medically supported weight loss with our customized plans gives you a one-on-one coach for habit health, nutrition guidance, and a healthy community to create optimal conditions for healthy, sustainable weight loss that protects your muscle mass. There are several affordable options.
Next Steps for LifeMD and the Medically Assisted program:
Thank you! We will connect with you for a short follow-up call.
Should be Empty:

Let's Get Started!

Background

Where You Are Now

Sleep

Hydration

Movement

Mind

Eating Habits

Weight

Surroundings

Medically Assisted Weight Loss

Thank you! We will connect with you for a short follow-up call.