Your Transformation Starts Now!
So happy you are here! Please click the photo above for a short introduction to the Metabolic Reset. The questions below help me understand what brings you here and how this program will be a strong fit for you.😀
Name
*
First Name
Last Name
Preferred Email
*
example@example.com
Date
*
 -
Month
 -
Day
Year
Today's Date
Address
*
City
*
State
*
Two Letter Abreviation
Zip Code
*
Phone Number
*
Format: (000) 000-0000.
Date of Birth
 -
Month
 -
Day
Year
Date
How did you hear about our program?
If you were referred, name of person who referred you.
Where are you and where do you want to be?
What would you like to accomplish with your health? (select all that apply)
*
Weight loss
Weight gain
Build/Retain muscle
Improved sleep
Gain energy
Better response to stress
Reduced inflammation
Other
Describe where you are with your health right now. (current weight, sleep habits, stress level, energy level, etc)
*
What does a typical day eating/drinking look like for you? (anything that goes in your mouth: Starbucks, alcohol, snacks, meals, vitamins, etc.). Feel free to distinguish between a "good day" and a stressful/busy day. Please include what time you have your first meal of the day and how many times you eat throughout the day.
How much do you typically spend on food, beverages & vitamins per day?
< $10
$10-$15
$15-$20
$20+
Do any of these apply to you?
High blood pressure
High cholesterol
Type 2 Diabetes
Insulin resistance
Medically Supported Weight-Loss Drug/GLP-1 Shot
Gout
None
Other
Describe where you would like to be in your health (physically/mentally, weight, clothes size, etc).
*
0/330
What have you tried before to lose weight/manage your health habits? (Weight loss programs, fitness programs, medications/surgeries, etc)
Please describe WHY you are interested in getting healthy. What is your main motivation? (feeling better, looking better, relationships, special event, activities, etc.)
*
0/330
Describe your current activity level (anywhere you are is OK!):
Walk
Strength training
Sports
Occassional actives with kids
Physically strenuous job
Not much exercise at all
Other
Where would you like to be with your physical activity (short-term or long-term)?
*
Goal Weight
*
Current Weight:
*
Height
*
Age:
Do you have any food allergies?
*
On a scale of 1-10, how committed are you to making lasting changes in your health?
Not so sure
1
2
3
4
5
6
7
8
9
Let's do this!
10
1 is Not so sure, 10 is Let's do this!
Is there anyone in your life who would want to get healthy with you? It's so much fun to do this with a friend or family member and surround yourself with a healthy community.
Is there anything else you would like to share with me?
Thank you for completing my questions. Please text me @ 917-453-6784 to let me know you submitted your answers so we can set up a time to discuss which program is right for you. Your first step toward better health is complete! I'm so excited to be your coach! 💖~ Andrea Walsh
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