Complimentary Health Questionnaire

1
What is your name?
First Name
Last Name
2
Describe your current health. Do you take any medications? Any medical conditions being treated by a physician or healthcare provider?Current Health
3
What would you like to improve with your health?If you could not fail, what is does your ideal health look like? What are your goals?
4
Are you considering or currently using any weightloss medications (like Ozempic, Wegovy, Mounjaro, semiglutide)?
No
I’ve considered
I’m currently using a weightloss medication
5
What do you think are your biggest hurdles, struggles, or challenges? What is making it difficult to accomplish your goals?What is missing?
6
What is your biggest motivation for wanting to change?How ready are you?
7
Do you get a good night's sleep?Sleep
Please Select
Please Select
Yes, I get adequate sleep and feel well rested in the morning.
Meh.
I have difficulty falling asleep, staying asleep, or do not feel well rested in the morning.
8
How active are you during the day?Activity & Excercise
Please Select
Please Select
Very Active, Consistent Exercise Routine, or Averaging 10,000+ steps per day with just daily activity
Fairly active during the day but no consistent exercise
Fairly active, but I'd like to add more intentional movement
Sedentary, and I don't see that changing right now
Sedentary, but I'd be interested in starting a new routine
9
On a scale of 1-10, rate your energy level throughout the day.1 = dragging, 10 = energizer bunny
10
How much water do you drink on average daily? And what other drinks do you enjoy routinely?Hydration Status
11
Describe a typical day of nutrition. How frequently do you eat? What kinds of foods do you enjoy most?Current Eating Habits
12
How often do you eat out? What types of food do you typically enjoy when eating out?Current Eating Habits Continued
13
The typical American spends between $15-$20 a day on food. Does that sound about right for you?Current Spending
14
On a scale of 1-10, how ready are you to make true lifestyle changes to accomplish your goals and maintain them long term?1 = just considering it, 10 = desperately need change and was ready a month ago!
15
Thank you for telling me more about yourself and your goals! I would love to set up a quick phone call to share more about our program and the nutrition plan that best matches your needs.* This field is required.How can I best reach you?
Please enter a valid phone number.
16
May I text you at the phone number above?
YESNO
17
How did you find me?I give wellness credits for referring, so if someone referred you, please let me know!
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