Goals & Health Assessment Form
This should take about 5-10 min to complete.
Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Would you like information about the...
Weight Loss/Gain Programs (Complete Section 1)
Business Opportunity (Complete Section 2)
Both (Complete Both Sections)
Section 1
What you would like to accomplish with your health? (Weight loss, improved sleep, better response to stress, etc.)
What is your main motivation for wanting to make changes to your health? Why is now the right time to make these changes?(Relationships, activities, how you will feel, etc.)
Tell me about your health: Do you have any allergies or medical conditions that could influence which Program we choose?
Are you Pregnant?
Yes
No
Are you nursing?
Yes
No
Are you taking any medications for:
Diabetes
High blood Pressure
Lithium*
Thyroid†
Coumadin (Warfarin)‡
Other medications:
Do you have the following:
High Blood Pressure
Diabetes Type I
Diabetes Type II
Gout
Gluten Intolerance orSensitivity
Soy Allergy orIntolerance
Food Allergies
How would you describe the quantity and quality of your sleep?
On a scale of 1-10, what is your energy level throughout the day?
How would you describe the quantity & quality of the activity youdo each week?
How many days a week do you exercise? What kind of exercise do you engage in and for how long? (0 - 7 days; walking/HIIT workout 45 min)
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? If you could change one thing about what you do what would it be?
Are there any unhealthy habits you can identify that should be improved upon?
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?
Are you comfortable sharing your age?
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? If so, what has been difficult for you about losing and maintaining the weight?
On a scale of 1-10, how healthy would you rate your surroundings? (Do you have healthy and active friends, supportive family, keep junk food in the house, etc.)
Is there anyone in your life who would like to get healthy with you?
Is there anything else you think I should know about your health?
Do you have any questions?
If I could give you a money back guarantee, would you give it a one month try?
Appointment-Please schedule the best time to connect. M-F We can not guarantee our availability but will confirm with you before the call.
Section 2- Business Opportunity (Even if you do not complete, Please Open to Submit Section 1)
Please share what intrigued you to learn more about this business opportunity?
What are the most important things in your life right now?
What do you currently do for work? How long have you done it? Do you love it?
This business offers both the ability to create IMPACT and INCOME; do both of these things motivate you?
What kind of income would be attractive to you?
Do you have specific goals you would like to achieve within the next 1-2 years?
In order to have a successfully growing business one must be caring, hardworking, and coachable. Are you all of the three?
Schedule a time to connect. My availability is M-F:12:15, 3,4,7,8/Sat: 8-12 (PST)
Submit
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