Language
English (US)
Türkçe
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
What you would like to accomplish with your health (Weight loss, improved sleep, better response to stress, etc.)?
*
What is your primary motivation for wanting to make changes to your health (Relationships, activities, how you will feel, etc.)?
*
What do you need the most support with in your journey? Where do you feel stuck?
Mindset
Personal Development
Nutrition
Support System/ Community
Accountability
Goals are EXTREMELY important. Please describe why you think you would benefit working with me. What goal(s) would you love to achieve with this support?*
What has been your biggest challenge in reaching this goal(s)?
What have you tried in the past to reach this goal(s)? Be specific.
How committed are you to changing your lifestyle? 1 not ready, couldn't care less" and a 5 being "I must make this change now!
1
2
3
4
5
Not at all
!00% in
1 is Not at all, 5 is !00% in
Why is it so important to make this change now?
Does your spouse/significant other support your health & fitness journey? (Meaning they will give you a thumbs up on whatever you decide)
Yes
No
Not Applicable
Are you taking the following medications, or any medications for:
Diabetes
High Blood Pressure
Thyroid
Coumadin (Warfarin)
Lithium
None
Other
Do you have the following:
High Blood Pressure
Diabetes Type I
Diabetes Type II
Gout
None
Other
Do you have any of the following allergies:
Gluten
Soy
Eggs
Dairy
None
Other
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Personal Info
Page 2 of 7
Birthdate | Age:
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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5
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31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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1920
Year
Weight & Height
*
Desired weight
*
Share a bit about your life...About your family? Are you currently working? Favorite hobbies? etc.
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Sleep Habits
Page 3 of 7
How many hours of sleep do you get in a typical night?
*
8 or more
6-7
Less than 6
How would you describe the quality of your sleep?
*
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Motion
Page 4 of 7
How many days a week do you currently exercise?
*
What types of physical activity do you enjoy?
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Mind
Page 5 of 7
On a scale of 1-10, how fulfilled are you?
*
1
2
3
4
5
6
7
8
9
10
1 is , 10 is
What area of your life tends to be the biggest stress for you?
*
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Food and Hydration
Page 6 of 7
How many meals do you eat per day
*
How many snacks do you eat per day
*
How soon after waking do you eat something?
Please Select
30 minutes
1 hour
more than 1 hour
lunch time
How many ounces of water do you drink per day?
*
How many times do you eat out per week? (Including Fast Food)
*
1-2
3-4
Daily
Never
How much a month would you say you personally spend on food? All eating out, gas station stops, coffee, soda shops, energy drinks, Costco/sams club, grocery store
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Healthy Finances
Page 7 of 7
Financially speaking, I am...
Very comfortable
Have enough for my needs
Feel strapped
Concerned about making ends meet
Choose not to answer
My Current Employment is...
Very fulfilling
Pays the bills, but I don't love it
Can't quite make ends meet
Other
Are you interested in learning more about helping others with their health while also earning a great income?
Yes, Very!
I am curious
Maybe
Not at this time
I realize I am booking a real time call with Elicia and I promise to respect her time by showing up on time for my call.
Yes
No
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