Health Survey- Marylee Lajoie
READY to make a change? Want to have a different relationship with food and finally achieve your weight loss goals permanently? This program has changed my life and my mission is to share it with everyone. What I do with my clients is powerful, FUN, and life changing....we will do so much more than counting macros or calories. We dig deep so that you are finally able to step into the best version of yourself. Be as detailed and honest as possible when you fill out this form. As your coach I will guide you in how to lose weight, but also how to achieve YOUR personal health goals. You CAN do this!
Full Name
*
First Name
Last Name
E-mail
example@example.com
Best number to reach you on
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Age
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, longevity, look hot in that outfit, etc. There is NO wrong answer)
Is there any food allergies or other allergies that I should be aware of?
Medical
We can discuss some medical considerations or prescriptions when we chat.
Do you have any pre-existing health conditions?
Diabetes- Type 1
Diabetes- Type 2
PCOS
Kidney DIsease
Gout
N/A
Other
Sleep
How many hours of sleep do you typically get?
How 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?
Coffee
Soda
Tea
Alcohol
Motion & Stress
Please describe your current exercise routine. No exercise is required on this plan.
What do you do for work?
What other stressors are in your life besides your job?
Eating Habits
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)
Weight
Current Weight: (completely confidential)
In a perfect world, if you could not fail, 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?
The Solution
This program has 4 components: Coaching, Community, Education & Nutrition. You will use all 4 components and each one is important in reaching your health goals and keeping those results long term. Are you ready to commit yourself?
Engaging with your coach will be important for your success. Choose all that apply:
I would love to talk with someone regularly for accountability
I would contact you occasionally if I have a question
I will enjoy interacting via text messages and that is enough for me
Which best describes your current health:
I've been in a good place before and I understand the concept.
I'm on a first name basis with every drive thru worker in town and I'm not sure how to get back on track.
I keep trying, but I have a hard time finding will-power to stay on any plan long enough to see results.
I think I'm doing everything right, but I'm frustrated with my results and don't feel like I'm losing weight at the rate I should.
I'm at my health goal but I'm struggling with figuring out how to maintain.
Are you interested in talking with me or another coach about this program and how it might work for you?
YES, let's set up a phone call asap.
YES, can we talk in the next couple weeks?
Maybe, I need more information.
No, but I know someone who needs this.
Leave me alone.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
THANK YOU for participating in my survey.
coach.optavia.com/maryleelajoie You may also email me at mlajoie4@tx.rr.com or 214-636-2419
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