Optimal HEALTH is for you !!!!

Optimal HEALTH is for you !

Fill out to the best of your knoeledge & get ready to feel and look amazing!!
Tell me your Full Name :)

First NameLast Name
Email
example@example.com
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Where do you live?

Street Address Line 2

CityState

Zip Code
Date of birth

MonthDayYear
How did you hear about our program ?
if you were referred , name of person who referred you.
Awaken- Let's Discover where you are and where you want to be!!
Right now, how would you describe your overall health? (Weight, sleep, stress, energy , etc)
Describe where you would like to be in your Health ...
Please describe WHY you are interested in getting healthy ( What is your main motivation .. relationships, activities, how you feel, etc..)
When was the last time you remember feeling your best in your health or being at you ideal weight or size ( if that is part of your goal)?
MEDICAL
Are you.....
Do you have the following?
Are there any food or other allergies that I should be aware of?
Are you taking any medications for/ like
Are you taking any other medications or have other medical conditions that could influence which program we choose?
SLEEP
How many hours of sleep do you typically get ?
What time do you typically go to bed?
What time do you typically wake up?
How is your quality of sleep?
Do you wake up feeling rested ?
HYDRATION
How much water do you drink each day ?
How much Coffee&/or Tea?
How much Soda?
How much Alcohol?
MOTION
How would you rate your energy level?( on a scale of 1-10)
How many times a week do you exercise?
What physical activities do you participate in?
Are there things you can't do that you would like to be able to?
EATING HABITS
How many meals per day do you eat ?
How many times per week do you eat out ?
When do you eat your first meal ?
When do you eat your last meal?
What kind of snacks?
WEIGHT
Curent Weight?
Goal Weight?
Height?
ARE YOU READY TO COMMIT TO YOUR HEALTH?
SURROUNDINGS
How healthy would you rate your surroundings? ( on scale of 1-10)
Do you have healthy & active friends, supportive family, keep junk food in the house, etc?
Is there anyone in your life who would like to get healthy with you?
Thank you for your thoughtful and honest answers regarding your current habits. Habit building is the key to long term success. I appreciate you taking the time to complete this form and would love to chat with you further to recommend which program would be the best fit for you. I will contact you to schedule an appointment.
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