Wellness Journey Tribe Health Assessment

Don't give up on the person you are becoming. . . . . .

Real people. Real results. Real science.This isn’t another fad or quick fix — it’s a proven, medically-designed system that actually supports your metabolism and addresses the things so many of us struggle with… insulin resistance, Type 2 diabetes, high blood pressure, high cholesterol, and feeling stuck in our own bodies.If you’re ready for change, I would love to walk alongside you.This health journey truly is life-changing, and you don’t have to do it alone.With simple, structured nutrition, an uplifting community of people just like you, and a coach (hi, that’s me!) who’s been exactly where you are… you will have every tool you need to succeed.If you’re curious or feeling that little nudge, fill out the form below and let’s schedule a free health assessment. Together, we’ll find the program that fits your goals and your life.Let’s get you feeling amazing again. ❤️
Today's Date

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Name

First NameLast Name
Birthday

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
How did you hear about our program ? (Family, Friend, Facebook, Instagram)
What are yyour top health goals right now (select all that apply)

Other
List any medications you are taking (Thyroid, Anxiety, Depression, MSWL injections , Diabetes meds or Injections?
Are you pregnant?
Are you nursing?
Do you have any of the following conditions:

Other
Do you have any allergies or medical conditions not mentioned above that could influence the system we design for you?
Do you have any food aversions - tastes, textures, etc.? Please list below.
What situations or factors are making your life so difficult that you cannot prioritize your health.
What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc
Tell me about a time in your life when you were healthier? What has changed between then and now?
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?

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1 is HORRIBLE, 10 is EXCELLENT
Are there things you can't do that you would like to do?
How many days a week do you exercise? (0-7 days) Exercise is NOT required in the weight loss phase
On a scale of 1-10, how fulfilled are you with where you are in your health & life currently?

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1 is NOT AT ALL, 10 is VERY FULFILLED
On a scale of 1-10, how much do you worry about your health, family, life in general currently?

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1 is NOT AT ALL, 10 is ALL THE TIME
What area of your life tends to be the biggest stress for you?
What do you do for work?
Do you spend most of your day moving around or sitting at a desk ?
What is your current work schedule ? Mon-Fri ? Hours ? In office or work from home?
On a scale of 1-10, how much do you enjoy what you do?

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1 is I HATE IT, 10 is VERY HAPPY
What has been your biggest challenge with weight loss or energy in the past ?
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? Include beverages, snacks, etc.
The average American spends approx. $15-$20 a day/person on groceries, beverages, supplements, snacks, dining out, etc. What would you guesstimate is your average?
Do you enjoy drinking water?
How many ounces of water do you drink per day?
Do you drink other beverages, such as:
How much alcohol weekly or monthly do you consume? What are your drinks of choice?
Do you prefer sweet foods, savory foods, or a blend of the two?
What is your current age?
How tall are you?
How much weight do you want to lose?
If you had a 100% guarantee you could lose this weight, would you start today?
Have you tried to reach these health goals in the past? If so, what have you tried?
Is there anyone in your life who you would like to get healthy with you?
Is there anything else you think we should know about your health?
ARE YOU READY TO COMMIT TO YOURSELF?
What is one question you hope I don't ask you?
This program has 4 components: Coaching, Community, Education, and Nutrition. You will utilize all 4 components equally. Each one is just as important as the other for reaching your health goals and maintaining your results long-term.

You will understand how your body and brain can function optimally.
Are you ready to commit to yourself?
Engaging with your coach is very important. Choose all that apply.
Additional comments you want me to know:
Name of person who referred you

First NameLast Name
Should be Empty:

Don't give up on the person you are becoming. . . . . .

SLEEP & ENERGY

ARE YOU READY TO COMMIT TO YOURSELF?