The Metabolic Reset
These quick questions help us understand what brings you here and whether this reset is a strong fit for you. Answer what you feel comfortable with.
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Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
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Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Who referred you to us?
If you were referred, or you saw someone's social media post, enter their name here.
Preferred Method of Initial Contact
Text
Call
Email
Where did you find us?
Facebook
Instagram
Friend
If you selected friend, please specify their name?
Have you taken the metabolic quiz before?
Yes
No
Describe your perfect day in your healthiest, strongest, most confident body. Describe it to us like in a movie.
What part of that picture are you missing most now?
What would change first for you or your family if you got that part back?
YOUR CURRENT METABOLIC SYMPTOMS
Current Symptoms
Fatigue and low energy
Poor digestion and bloating
Difficulty losing weight
Mood swings or irritability
Sleep disturbances
Brain fog or difficulty concentrating
Slow Metabolism
Hormone Imbalances
Frequent hunger or overeating
Sugar cravings
Other
On a scale of 1 - 10 how out of sync does your metabolism feel?
1
2
3
4
5
6
7
8
9
10
What have you tried so far to fix this?
Diet changes
Exercise routines
Supplements
Detox programs
Medication
Therapies or coaching
Fad diets
None
Other
Why do you think those things have not worked long term?
How is this struggle affecting your life right now?
Reduce energy
Reduced motivation
Declined work productivity
Mental health challenges
Lower confidence
Impacting relationships with family/friends
Physical discomfort or pain
Social withdrawal
Financial Stress
Mobility problems
Other
If nothing changes in the next 6-12 months, what do you think happens?
What matters most to you right now?
Improved energy and vitality
Weight loss and body composition
Mental clarity and focus
Better sleep quality
Emotional balance
Hormonal balance
Long term health and longevity
Other
What support do you feel you need most?
Accountability and coaching
Simple structured meal plan
Exercise guidance
Mindset and motivation support
Stress management techniques
Community Support
Other
What current patterns or habits hold you back the most?
If there was a proven path that burns fat, protects 98% of your lean muscle mass, and reverses metabolic dysfunction, how open are you to following it exactly as designed?
Very open and committed
Somewhat open, need more information
Not sure yet
Not open at all
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?
Are you prepared to invest time, energy, and money into your health if the plan fits you?
Yes
Yes but need details
Not right now
If accepted how soon would you want to start?
Right away
This week
In the next two weeks
Other
Anything else you want me to know before I review your application?
Background
Do you have any of the following?
Diabetes - Type 1
Diabetes - Type 2
High blood pressure
Gout
High Cholesterol
Insulin Resistant
Please describe your dietary restrictions and/or food allergies
Hydration
For each of the following beverages, please enter the amount you drink
each day
in
ounces
.
Water
Coffee
Soda
Tea
Energy Drinks
Alcohol
Motion
How would you rate your energy level?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What kind of physical activities do you participate in?
Are there things you would like to do that you are currently unable to?
Stress
How would you rate your stress level?
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
What do you do for work?
Eating Habits
How many meals per day do you typically eat?
What do you snack on?
How many times a week do you eat out?
When you do eat out is it usually:
Fast food
Sit-down
A little of both
Weight
Current Weight
Height
Surroundings
Is there anyone in your life who would like to get healthy with you?
Do you have healthy & active friends, supportive family, do you keep junk food in the house, etc?
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Yes
Save and Continue Later
Submit
Save and Continue Later
Submit
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