Transformers Coach Team - Health Assessment

Info Video & Health Assessment

If you are someone who wants to reclaim your health and change your lifestyle you've come to the right place. I have helped countless people just like you achieve personal transformation with our very simple system
Step 1:

Start by watching this short video to learn how our program works.
Step 2:

Fill out the questions below to help us determine which plan to point you towards.
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Age *

18-29 30-49 50-69 70+
How did you hear about me? *

Facebook Instagram Referred by a friend Met in person Other
If you were referred here, please tell me who sent you.
Be as detailed as you like and tell me what would you like to accomplish with your health (Weight loss, more energy, improved sleep, better response to stress, etc.)? *
Knowing your “WHY” is important. So tell me what is your motivation for wanting to make changes to your health (Relationships, activities, how you will feel, etc.)? *
Check all that apply: *

I have High Blood Pressure I have Type 1 Diabetes I have Type 2 Diabetes I have Gout I am Pregnant I am a Nursing Mother I have 100lbs or more to lose I am underweight and need to gain I am a Vegetarian I am a Vegan None of the Above Other
Are you taking any medications for: *

High Blood Pressure Diabetes Thyroid Coumadin (Warfarin) Lithium None of the Above Other
Do you have any of the following allergies: *

Gluten Soy Eggs Dairy Nuts None Other
Current Weight & Height *
Desired Weight *
BMI Chart

You want to be in the green
When was the last time you were at your goal or at a healthy BMI? *
What would it mean to you to be at that healthy weight again? *
How many hours of sleep do you get in a typical night? *

8 or more 6-7 less than 6
How would rate the quality of your sleep? *

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Great
How many days a week do you exercise? *

None 1-3 3 or more
What type of physical activity do you enjoy? *
How would you rate your energy level? *

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
How do you rate your stress level?

1

2

3

4

5

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8

9

10

1 is Low, 10 is High
How many meals do you eat a day? *
How many snacks do you eat a day? *
How much water do you drink a day? *

Less than 16oz 16-32oz 32-64 oz more than 64oz
How many times do you eat out per week? (Including Fast Food) *

1-2 3-4 Daily Never
Typically American's spend between $15-$20 A DAY on food. How much do you believe you spend? *
Can you identify any unhealthy patterns in your eating habits *
How committed are you to making a change in your health? What is your health worth to you? *

1

2

3

4

5

6

7

8

9

10

1 is Not at all, 10 is Very
Are you willing to invest 15 minutes a day to learning new habits that will support lifelong transformation? *

Yes Maybe No
Your Schedule (choose all that apply) *

I work full or part time away from home I work full or part time from home Unemployed Retired Student Heavily involved with family/community/group activities Other
Are you interested in receiving some information about how you could earn additional income by simply sharing health & hope with others? *

Yes No
Is there anyone in your life who would like to get healthy with you? Our clients who do this with a partner or friend tend to have better success! *
What is the best day of the week to contact you to go over your results (check all that apply) *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
What is the best time of the day to contact you? *

Morning Afternoon Evening
What time zone are you in? *

Pacific Mountain Central Eastern
Are you on Facebook? *

Yes No No, but Im willing to join for my health
Are you familiar with ZOOM? *

Yes No
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Info Video & Health Assessment

Step 1:

Step 2:

BMI Chart