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?
*
Poor
1
2
3
4
5
6
7
8
9
Great
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?
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
How do you rate your stress level?
Low
1
2
3
4
5
6
7
8
9
High
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?
*
Not at all
1
2
3
4
5
6
7
8
9
Very
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
Submit
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