Fall Back into Healthier Habits
6 Week Challenge from 9/14 to 10/25
Name
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First Name
Last Name
Phone Number
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Format: (000) 000-0000.
E-mail
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example@example.com
Briefly tell me a little bit about yourself and your current lifestyle (home life, work situation, schedule, activity levels, literally anything you think I should know!)
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Anything in your medical history I should be aware of?
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What are your goals for the 6 week challenge?
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Why are those goals important to you?
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On a scale of 0 to 10 (10 = best), rate your current average energy levels.
On a scale of 0 to 10 (10 = best), rate your current health.
On a scale of 0 to 10 (10 = best), rate your consistency with "healthy nutrition and fitness habits"
Do you have Facebook? If so, what is your name on there so I can add you if we are not already friends. We will have an accountability group, but it is optional to join!
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This 6-week challenge is intended for general educational and wellness purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. The information and activities provided are not intended to prevent, diagnose, treat, or cure any medical condition. Before beginning any new exercise, nutrition, or lifestyle program, consult with your physician or other qualified healthcare professional, especially if you have a medical condition, take medications, are pregnant or breastfeeding, or have concerns about your health. Listen to your body and participate at a level that is appropriate for you. By participating in this challenge, you acknowledge that you are responsible for making decisions about your own health and well-being. Please write "I agree" below.
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Cost: $25 (Complete the challenge and you can actually use this $25 credit towards one of our PT or Nutrition services at Building Resilience!!) I would prefer to pay with:
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Check (made out to Jenna Maag - drop off at Building Resilience)
Venmo (@jenna-maag)
Cash (can be dropped off at Building Resilience during open hours)
Submit
Should be Empty: