Welcome to Exploring Optimal Health
Jason & Kari Robison
Transformation Specialists
Congratulations on reaching out to discover how you can create a lasting TRANSFORMATION in your LIFE with your health. Thank you for taking time to fill out the survey. We are excited to discuss with you the best program that will fit your health needs and goals
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Age
How did you hear about us or our program?
Please describe you WHY to becoming a healthier version of you! (What is your main motivation? Relationships, activities, how you feel, etc?)
When was the last time you remember feeling your best in your health or being at your ideal weight or size? (if that is part of your goal)
Medical
Are you Pregnant
Please Select
YES
No
Unsure
Are you Nursing?
Please Select
Yes
No
If yes, how old is your baby?
Do you have any of the following?
Diabetes- Type 1
Diabetes- Type 2
High Blood Pressure
Thyroid
PCOS
Kidney Disease
Other
Do you have any food allergies or dietary restrictions?
Please list any and all medications or supplements you are currently taking
Are you taking medications for any of the following?
Diabetes
High Blood Pressure
Thyroid
Blood Thinners
Other
Sleep
How many hours of sleep do you typically get each night?
What time do you typically wake up?
How is your quality of sleep? Do you feel rested when you wake up?
Hydration
How much water do you typically drink per day?
Do you consume any other beverages?
Coffee
Tea
Soda
Alcohol
Motion
How would you rate your daily energy level on a scale of 1- 10 (highest)?
Do you currently exercise? If so, how many times a week?
What physical activities do you participate in?
How would you describe your daily activity?
Stress
How would you describe your stress on a scale of 1-10?
What do you do for work?
Are there any other stressors in your life?
Eating Habits
How many meals do you eat today?
Do you snack 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 (If you feel comfortable to share)
If you could not fail, how much weight would you like 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 empowered to get healthy with you?
Submit
Should be Empty: