Transformation Readiness Survey
Let's see if you are truly ready to step into the best version of yourself!
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
Height
Approximate Weight
What you desire to achieve! Click on as many that apply to you!
Weight Loss
More Energy
More Self-Confidence
Less Reliance on prescription medications
Ultra-Health and Longevity
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Determination of Readiness
Your Goal: What do you want to accomplish?
Your Why: Why do you want to accomplish this? Who or what are you doing this for? What are some of your pain points (physical and/or emotional)? What happens if nothing changes?
On a scale of 1-10, what is your level of desperation to making this goal a permanent reality?
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Medical and Allergy Concerns
Health Concerns/Situations: Please select all that apply to you.
Pre-Diabetic
Type 1 Diabetic
Type 2 Diabetic
Thyroid Disease (taking Levothyroxine daily)
Taking a blood thinner daily
Have Gout
Currently breast feeding
Do you have any food allergies or sensitivities? Please list below.
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Habit Analysis
How many ounces of water do you drink per day
0-12 ounces
12-36 ounces
36-64 ounces
64-100 ounces
100+ ounces
Other
Do you have a "PLAN" each day for eating?
YES
NO
How many meals do you eat per day?
How many snacks do you eat per day?
Habit Deficiencies: Check all that need serious work/improvement
Habit of Healthy Eating
Habit of Healthy Hydration
Habit of Healthy Sleep
Habit of Healthy Motion
Habit of a Healthy Mind
Habit of a Healthy Environment (People AND Places)
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Should be Empty: