Your Health Starting Point
Just wait... a few weeks with me, yes, just weeks, and this will all change! All of these questions (except the first three for contact) are optional. I hope you’ll take a few mins to fill this out, but if you’d rather chat on the phone I will give you a call - just submit what you want! I am Rebecca Lange, Independent Certified OPTAVIA Coach www.MyJourneyToAHealthyMe.com 336-202-3316
What is your name?
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Right now, how much do you weigh? If you were like me and didnt get on the scale, how much do you think you weigh?
Right now, how would you describe your overall health? Physical, mental, energy, self confidence..
Why do you want to get healthy? What do you think will be different in your life when you make healthier choices for food, movement, sleep, etc.?
What do your dream health goals look like?
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 totally confidential. Share away...
Do you have any questions for me? Ask here:
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
Rate the quality of your sleep?
How many meals do you currently eat per day?
Do you exercise?
How many pounds away are you from feeling confident?
How many other weight loss programs have you tried? (I tried at least 30 in my 40 years of life!)
On a scale of 1-10, how committed are you to getting to your health goals?
I am 100% confident in the program and its ability to work. You are the only variable to the program's success. It’s simple, not always easy, but the things that matter in life are never easy. I know you can reach your health goals with my help and support, but I am going to say something very pointed: 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? I was. BUT, my life was a struggle 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 excited to work with you!
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