Let's Go!!!!
Imagine where you will be 3 months from now!
Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please read the questions carefully and answer each one honestly. Check Yes or No. Your answers will help us get you on the correct plan!!
Are you being treated for any of the following:
Gout
Type 1 Diabetes
Type 2 Diabetes
Thyroid Disease
High Blood Pressure
High Cholesterol
Heart Complications
Other
Are you:
Pregnant
Nursing
Pre-Menopause
Post-Menopause
Height
Right now, how much do you weigh? If you don't know exactly, how much do you think you weigh?
How many pounds away from feeling confident are you?
How many meals do you currently eat per day?
Rate the quality of your sleep.
Do you exercise?
How many other weight loss programs have you tried?
On a scale of 1-10 (10 being the most), how committed are you to getting to your health goals?
Right now, how would you describe your overall health? Physical, mental, energy, self confidence.
Why do you want to lose weight? What do you think will be different in your life when you get to a health weight (which you can!)?
What would you change about your life right now to make it better? I get some deep responses here and I want you to know this is confidential. Before I started losing weight, there were a lot of things in my life that felt out of control. All were big reasons I ate, so I get it. Share away...
I am 100% confident in the program and its ability to work for everyone. Literally, you are the only variable to the program success. Its simple, not always easy, but the things that matter in life are never easy. I know that you can lose the weight you want with my help, but with you being the only variable, if you fail, it's your fault. If you succeed, it's also your fault. How does that make you feel? Scared? Good! I was too. But, my life felt chaotic because of all the things I could NOT control. I decided to be excited that I could control one part of my life. How do you feel now? I am so exited to work with you!
I have read, understood and completed this questionnaire.
Initials
*
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