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.
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
Back
Next
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?
Back
Next
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.
Back
Next
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)
Submit
Should be Empty: