Inspire Health Survey… Yes!! I want to be healthier!

The world is searching for quick-fix weight-loss solutions. But quick fixes don't work. Our program is different because we will help you learn and adopt new habits, which can lead to lifelong health and wellbeing. Are you ready to get your mind and body working together for you?

You're one choice today can change your tomorrow. The biggest obstacle is that first step. Take that first step by reaching out and let' s chat about your goals. Let's work together to change your story today!
First & Last Name *
Email *
example@example.com
Cellular number to be reached at by text or call (include area code) *
Age
How did you hear about us or our programs?
Please describe WHY you are interested in getting healthy. (your main motivation ie; relationship, desire to do more physical activities, how you feel, etc) *
Health & Allergies
Are you pregnant or nursing?
Are there any reasons why you could NOT lose weight? This could be physical, medical or due to a medication you are on. Explain in detail if yes. *
Are you taking any medications or supplements currently?:
Do you have ANY food allergies or other allergies that we should be aware of? ANY AT ALL in any form, please describe or say NONE. *
Sleep
How many hours of sleep do you typically get per night?
What time do you usually wake up?

Hour Minutes

AM/PM Option
What is your quality of sleep and do you wake up feeling rested?
Hydration
How much water do you drink each day?
Do you consume any other beverages *

Black Coffee Coffee with cream Coffee with sugar Coffee with cream and sugar Soda Tea (hot or hold) Alcohol
If you consume alcohol, how often?
Motion

(it is not necessary to do a work out routine on our programs, we are simply finding out your current routine)
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 per week.

Only when I have a chance, usually less than once a week 1-2 days 3-4 days 5-6 days
What type of physical / exercise activities do you participate in?
How would you describe your daily activity level?
Stress
How would you rate your stress level on a scale of 1-10? (1 being the least amount of stress and 10 being the most)
What do you do for work?
Are there any other stressors in your life?
Eating Habits
How many MEALS per day do you eat?

1-2 3-4
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)
Weight
Current Weight *
In a perfect world, how many pounds would you want to lose? *
Height: *
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?
If you were to chose to be on our program, where would we send your kit?
Street Address
Street Address line 2
City
State
Postal / Zip Code
Should be Empty:

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Health & Allergies

Sleep

Hydration

Motion

Stress

Eating Habits

Weight

If you were to chose to be on our program, where would we send your kit?