RiseUp Health & Wellness Consultation

RiseUp Health & Wellness Consultation

Personalized wellness starts with you: please share some basic information and we will be in contact with you soon!
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number. We will connect by text message to arrange a virtual session.
How did you learn about RiseUp Health & Wellness? *
List your top 3 health and wellness challenges that you'd like to work on: *
Describe your current fitness routine or daily activity level: *
Would you prefer to exercise at your house/outdoors or at a gym?*

At home/outdoorsAt a gym
How many steps do you walk most days?*

less than 1,0001,000-3,0003,000-5,0005,000-7,0007,000-9,0009,000-10,00010,000 or moreI am not sure
Do you have a fitness watch? (ie. garmin, apple, fitbit)*

YesNo
What programs, diet, memberships, products or approaches have you tried in the past, to improve your health & wellness? *
What worked well or what did you enjoy about the previous programs, diet, memberships, products or approaches you've tried? *
What were the biggest challenges or disappointments about the programs, diet, memberships, products or approaches you've tried in the past? *
How many ounces of water are you currently drinking each day? *
Which meals do you eat on a daily basis?*

BreakfastMid-morning snackLunchMid-afternoon snackDinner
Have you tried intermittent fasting?*

YesNo
List any food allergies or sensitivities that you are aware of: *
How many hours do you sleep each night, on average?*

3-55-67-89 or more
How much do you currently weigh (lbs)?*
What is your ideal weight goal? *
How tall are you (ex. 5ft 2in) *
Check any of the following symptoms you are currently experiencing:*

Joint aches/painsNumbness or tingling in extremitiesHair loss or thinningDiarrhea more than once/weekBowel movements less than once/dayDifficulty concentratingAlways feel tiredMigraine headachesDifficulty falling asleepDifficulty staying asleepAcid refluxSkin rashesEczemaSeasonal allergiesAsthmaChronic neck and/or back painAnxietyInsulin dependent diabetesMenopause symptoms: night sweats, hot flashes, mood swingsHigh blood pressureHigh cholesterolAcneLow energyAdrenal Fatigue
How motivated are you to try new foods and eating practices?*

Not very, change scares me.I'm nervous but willing to try new things.What I'm doing now isn't working, let's go!
How motivated are you to try new movement routines or exercise plans?*

Not very, I hate exercising.I need to start slow, but I am ready!I exercise routinely, so let's step it up a notch!I love my current fitness routine and don't need any help.
What challenges or barriers do you anticipate as you take the next steps in your wellness journey? *
How soon are you hoping to take your next steps with RiseUp Health & Wellness?*

withing the next 24-48hrsby the end of this weekby the end of this monthI'm still exploring my options
Please list any medical diagnoses you've received from your medical team: *
Your information will never be shared and is always confidential.
Please list any over the counter medications, prescriptions, vitamins, supplements, energy drinks, protein bars or powders you are currently using. *
Do you have any medical devices implanted in your body?*

YesNo
If you answered yes to having an implanted medical device, please explain below. If you answered no, skip this question.
RiseUp Health & Wellness provides support with a variety of services. Which ones would you be open to try:*

DetoxGenetic analysisWeight lossInflammation
We have a variety of approaches we can take to help you feel your best and respect the individual preferences of each unique wellness partner. Which of these approaches do you identify with most?*

I would like to incorporate products that help me achieve quicker results.I don't mind giving my body more time to transform, as long as I am using a natural approach.I would be open to a combined approach, with some products as well as natural strategies.
RiseUp Health & Wellness is intended to provide wellness education only. We do not provide medical advice, and we do not treat, cure or prevent anything. Do you understand and agree to this statement?*

Yes, I understand and agree.I misunderstood and am not a good fit for RiseUp Health & Wellness.
What questions do you have?*
Should be Empty: