Let's Talk About Your Goals!
Name
Email
example@example.com
Phone
Format: (000) 000-0000.
When you reach your goals how will you feel?
Energized
Confident
Strong
Lean
Happy
Engaged/Connected
Motivated
Proud
Describe your health right now. (Your weight, physical health, mental health, energy, confidence, sleep, stress response...)
Why do you want to lose weight or get healthy? What will be different in your life when you do lose weight?
*
Do you have any food allergies?
*
Are you taking any medications for any of these:
High Blood Pressure
Diabetes Type I
Diabetes Type II
Gout
Thyroid
Coumadin (Warfarin)
Medically Supported Weight Loss Products (Ozempic, Wegovy, etc...)
Other
Have you utilized in the past or are you currently utilizing one of the following medically supported weight loss tools like Bariatric surgery, GLP1 shots, and/or pills?
*
Please Select
Bariatric Surgery
GLP-1 Shots (Ozempic, Mounjaro, etc...)
Weight Loss Pills
Other
NO
If YES, please explain here:
Let's talk about your current habits!
How many hours of sleep do you get in a typical night? Do you feel rested when you wake up?
*
On a scale of 1-10, what is your energy level throughout the day?
*
Do you exercise? Tell me about your activity level? If you do exercise, what do you enjoy doing?
*
On a scale of 1-10, tell me about your stress level? What are the main areas of stress in your life right now? Are there specific circumstances leading to higher stress?
*
How many meals and snacks do you eat per day? Is there a certain time of day you tend to become really hungry/snacky or the cravings attack?
*
Realistically, how many healthy meals (made of protein, veggies and healthy fats) can you prepare each day? (Some people struggle to even create one healthy meal, while others are really great at making 2 or 3 high protein meals.)
*
How many times a week do you eat out? And where?
*
Let's talk about drinks... water, coffee, soda, alcohol, tea... How often do you drink these and how much?
*
On a scale of 1-10 how motivated are you to lose weight and get healthy?
The stats from 2023 said the average American spends between $27.73 / day on food… That includes groceries, eating out, snacks, coffee etc… Where do you fall in the range between $19-$30+/day?
*
WEIGHT MANAGEMENT
How tall are you?
How much do you currently weigh?
What would you consider to be a healthy weight for you?
How have you tried to lose weight in the past?
SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (Does you have healthy and active friends, supportive family, keep junk food in the house, etc)
*
We know that health is contagious. When you get healthy, who are three people who will end up getting healthy with you?
Is there anything else you think I should know about you or your health?
FOR PREVIOUS CLIENTS
When you were on program before, which program did you do?
What part(s) of program did you like the most? What made you successful? Which parts of program were most challenging?
Submit
Should be Empty: