"HEALTHIER ME" CLIENT INTRO FORM

THIS IS WHAT "HEALTHIER ME" LOOKS LIKE FOR US...
Todd Shapiro & Gwen Bowman-Shapiro

Together, we shed 120 bs. resulting in our amazing mind and body transformations! After struggling with our health for many years, we are now able to enjoy an active lifestyle without lingering serious health concerns (high blood pressure, pre-diabetes, acid-reflux & neck/back pain.) It feels like we set the time clock back 10 years and we'll be f-o-r-e-v-e-r grateful for our reclaimed health & well-being.
As we continue to pass forward what we've learned and experienced... it's an honor, privilege and joy to have front row seats to our client's exciting transformation journeys. We feel extremely lucky for the opportunity to walk alongside our clients and celebrate their scale and non-scale victories over and over again! As a Psychotherapist, Todd brings over 40+ years of helping people deal with life issues and ultimately move their lives onward and upward. As a Training, Development & Support Coach with 22+ years of experience, Gwen helps people tap into their temperament strengths and to develop skills and competencies. Together, we bring years of experience, coaching and guidance to our clients.
How many times have we lost the same 20, 30 or 40+ lbs.?

This is what happened when we went on another food diet solely to change our body's shape and weight. We never considered that we're creating a new body that still has the old mindset, thinking patterns and habits.
From your past experiences, you may have developed doubts about yourself and have recurring feelings of failure?
- We know that 70% of Americans struggle to reach and maintain a sustainable healthy weight.
- Each year, over 45 million Americans go on a food diet to lose weight desperately seeking to shed extra fat.
- Approximately 85% of people who go on diets gain all of their weight back (and then some) within 2 years.
- The only habit created is dieting over and over again never knowing that successful weight management requires a simultaneous body & mind transformation to insure lifelong success.
Lifelong Body Transformation

On Day 1, based on our client's health goals and how quickly they want to achieve them... we walk them through a simple nutrition/hydration plan to support rapid and predictable weight loss. In their first week on program, they begin seeing weight loss results while enjoying: 1) low-to-no hunger or cravings, 2) more natural energy, 3) better daytime stamina, 4) increased flexibility & mobility, 5) improved sleep at night all resulting in a more active and fulfilling lifestyle journey.
Mind Reset & Transformation

As our clients are experiencing and achieving their successful body transformation, we're now coaching to a very inspired mindset. This is when we help them reset their thinking to align their mind's focus with their body's new shape. We help them dive into their "why" while identifying and understanding their: 1) impulsive trigger origins, 2) habit switching strategies and 3) we plug them into a vibrant community with other like-minded client and coaches. Program optimization and support are key in our client's health journey and we walk them through one baby step at a time for a lasting mind & body transformation. For our clients, some of the major conscious (and unconscious) factors in boosting their self-confidence and esteem is in understanding their unique emotional, physical and nutritional cycles and their associated cues, routines and rewards. That's where we step in with years of experience and help our clients excel.
What about your health & wellness?

Maybe you've tried everything and you may think that permanent better health isn't possible for you?
Maybe you've reached a place where you need help with a mind & body reset?
It's a new day. We believe in you so, for now... maybe just borrow our confidence until you find your own again?
Knowing your current reality is the first step in creating your own "Healthier Me".
All information shared is held private and confidential.

The below questions get the conversation started so, share as much as you feel comfortable with today. This info helps us know how to best assist in your journey towards optimal health & wellness. Please try to include any medical issues as this helps us determine which of our 10 health programs would be a best fit your goals and how quickly you want to achieve them.
Name*
Phone*
Email*
Preferred Method of Contact: Talk or Text*
Address*

Street Address

CityState / Province

Postal / Zip Code
Referred From?
STEP 1: AWAKEN & HEALTH
1. What would you like to accomplish with your health? This could be weight-loss, improved sleep, better response to stress, etc. *
2. What is your main motivation for wanting to make changes to your health? (relationships, activities, how you will feel)*
3. Remembering a time in your life when you were healthier: What has changed between then and now?*
4. Regarding your health: Do you have any allergies or medical conditions that could influence which program we choose?*
5a. Are you Pregnant?

NoYes
5b. Are you Nursing?

NoYes
6. Are you taking any medication for:

DiabetesHigh Blood PressureLithium*ThyroidCoumadin (Warfarin)Other
7. Do you have any of the following:

High Blood PressureDiabetes - Type 1Diabetes - Type 2GoutGluten Allergy or IntoleranceSoy Allergy or IntoleranceFood Allergy (Medically Diagnosed)Other
*Lithium: The healthcare provider may wish to adjust frequency of lab work for the Client and monitor. Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication. Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.
STEP 2: DAILY ROUTINE & HABITS
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?*
How would you describe the quality of your sleep?
On a scale of 1-10, what is your energy level throughout the day?*
MOTION
How would you describe the quantity & quality of the activity you do each week?
How many hours a day do you sit?
How many days a week do you exercise? (0 - 7 days)*
What types of physical activity do you enjoy?
MIND
On a scale of 1-10, how fulfilled are you?*
On a scale of 1-10, how much do you worry?
What area of your life tends to be the biggest stress for you?
What do you do for work?*
On a scale of 1-10, how much do you enjoy what you do?*
FOOD & HYDRATION
How many meals and snacks do you eat per day?*
When do you eat your first meal of the day?
How many times a week do you eat out? And where?
How many ounces of water do you drink per day?*
Do you drink other beverages? Coffee, soda, alcohol, tea, etc.
If so, how often and how much?
WEIGHT MANAGEMENT
Age*
Height*
How much do you currently weigh?*
What would you consider to be a healthy weight for you?*
Have you tried to lose weight in the past?*
What has been difficult for you about losing and maintaining weight?*
SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (healthy friendships, supportive family, home environment)*
Is there anyone in your life who would like to get healthy with you?*
Is there anything else you think we should know about your health?*
Should be Empty:

THIS IS WHAT "HEALTHIER ME" LOOKS LIKE FOR US...

Todd Shapiro & Gwen Bowman-Shapiro

How many times have we lost the same 20, 30 or 40+ lbs.?

Lifelong Body Transformation

Mind Reset & Transformation

What about your health & wellness?

Knowing your current reality is the first step in creating your own "Healthier Me".

All information shared is held private and confidential.

SLEEP & ENERGY

MOTION

MIND

FOOD & HYDRATION

WEIGHT MANAGEMENT

SURROUNDINGS