Wanda’s Survey - First Steps

Wanda’s Survey

with Coach Wanda Fischer
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First Name
Last Name
Email
example@example.com
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearToday's Date
Address
City
State
Two Letter Abreviation
Zip Code
Phone Number
Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Who referred you to our program?
If you were referred, name of person who referred you.
Awaken...Discover where you are and where you want to be!
Why are you interested in this program... (Weight gain, weight loss, nutrition, sleep, stress, energy, etc)

0/330
Describe where you would like to be in your health journey…(look better, confidence, etc)

0/330
Are there any food or other allergies that I should be aware of?

0/160
When was the last time you remember being at your best healthy (if that's part of your goal)?

0/330
HYDRATION
How much water do you drink each day?
How much tea, soda, Coffee?
MOTION
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 you Coachable?
Will you commit to at least a weekly zoom or phone call?
Will you do a weekly assessment/ progress post on social media?
Will you send a monthly evaluation report?
Will you participate in a Facebook group for accountability?
Are you open to look at Coaching or send referrals when people ask about the program?
What has been most difficult about maintaining your health in the past?

0/200
SURROUNDINGS
Who would you like to get healthy with you?
On a scale from 1 to 10 how serious are you about getting back your health?
Would you like to know your BMI?
Are you ready to start?

Other
Should be Empty: