Date
-
Month
-
Day
Year
Date
Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
I would love to hear what you would like to accomplish with your health. Please select all that apply.
Weight Loss
Weight Gain
Gain Energy
Better Response to Stress
Improved Sleep
Reduced Inflammation
Improved relationship with food
Increased physical fitness
Increased muscle definition
Overall health and wellness
Other
If other, please explain
What is your main motivation for wanting to make changes to your health? (Relationships, activities, how you will feel, confidence, etc.)
Can you tell me about a time in your life when you were healthier? What has changed between now and then?
Tell me about your health: Do you have any allergies or medical conditions?
Are you taking any medications for
Diabetes
High Blood Pressure
Lithium
Thyroid
Coumadin (Warfarin)
Other
If there are other medications, please list them here
Do you have the following
High Blood Pressure
Diabetes Type I
Diabetes Type II
Gout
Food Allergies
Other
If you selected food allergies, please explain (please list only true allergies)
If you selected other, please explain
How many hours of sleep do you get in a typical night?
On a scale of 1-10, what is your energy level throughout the day?
How many hours a day do you sit?
How many days a week do you exercise? (0 - 7 days)
What types of physical activity do you enjoy?
What area of your life tends to be the biggest stress for you?
On a scale of 1-10, how much do you enjoy what you do?
On a scale of 1-10, how much do you enjoy what you do?
How many meals and snacks do you eat per day?
When do you eat your first meal of the day?
How many times a week do you eat out? And where?
How many ounces of water do you drink per day?
Do you drink other beverages? Coffee, soda, alcohol, tea, etc. If so, how often and how much?
Are you comfortable sharing your age?
How tall are you?
How much do you currently weigh?
What would you consider to be a healthy weight for you?
Have you tried to lose weight in the past? If yes, what have you tried? How did it work
What has been difficult for you about losing and maintaining weight?
Who referred you to me?
How important is this to you on a scale of 1-10
Is there anyone in your life who would like to get healthy with you?
The average American spends approximately $13-$20 per day on on average on groceries, beverages, supplements, snacks, dining out, etc. What would you guesstimate is your average?
10
15
20
25
Is there anything else you think I should know about your health?
Shipping Address
Street Address Line 2
Street Address Line 2
City
State / Province
Postal / Zip Code
City
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