We Are Better Together!
I'm so glad you are here! My name is Laura Kleber and I have a love for health and wellness and guiding others to do the same. I help match people with a complete plan that includes personalized coaching, a support community, education and a nutrition-oriented mindset. You have already taken the first step just by reaching out here!
Name
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First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
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example@example.com
Did someone refer you?
What would you like to accomplish with your health? (select all that apply)
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Weight Loss
Medically Supported Weight Loss/Support
Build Muscle
Improved Sleep
Gain Energy
Better Response to Stress
Reduce Inflammation
Are you taking any of the following medications or have any of the following allergies? If medication/allergy/medical condition is not listed, please list in the other option.
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Diabetes Type I
Gluten Intolerance/Allergy
Diabetes Type II
Soy Allergy
High Blood Pressure
Food Allergies
Thyroid
Gout
Coumadin (Warfarin)
Lithium
High Cholesterol
None
Other
Are you taking any vitamins or supplements? Protein shakes or powders? Please list below.
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Are you pregnant or nursing?
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Yes
No
Do you have any allergies or medical conditions?
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Do you have any food aversions - tastes, textures, etc.? Please list below.
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What is your main motivation for wanting to make changes to your health? Relationships, activities, feeling better, your future, longevity, etc.
Tell me about a time in your life when you were healthier? What has changed between then and now?
How many hours of sleep do you get in a typical night?
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How would you describe the quality of your sleep?
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On a scale of 1-10, what is your energy level throughout the day?
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HORRIBLE
1
2
3
4
5
6
7
8
9
EXCELLENT
10
1 is HORRIBLE, 10 is EXCELLENT
Are there things you can't do that you would like to do?
Exercise is not required for our program. But if you do exercise, please describe your workouts. What types of physical activity do you enjoy in general?
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On a scale of 1-10, what is your average daily stress level?
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NOT AT ALL
1
2
3
4
5
6
7
8
9
ALL THE TIME
10
1 is NOT AT ALL, 10 is ALL THE TIME
What area of your life tends to be the biggest stress for you?
Is your typical day more sedentary or active?
Approximately what time do you get up and when do you eat your first meal of the day?
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How many times, on average, do you eat out or order in in a week?
About how many ounces of water do you think you drink per day? Do you enjoy water? Do you need flavoring or like it plain?
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Do you drink other beverages, such as:
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Coffee
Tea
Alcohol
Soda - with sugar
Soda - diet/zero calorie
If seeking weight loss, how much weight would you like to lose?
Have you tried other programs in the the past? If so, what have you tried?
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Are you currently using Medically Supported Weight Loss (i.e. Wegovy, Ozempic, semaglutide, etc)
I am not taking any of these medications.
I am taking one of these medications.
I am possibly interested in starting medically supported weight loss.
I am using one of these but have concerns (transition, muscle preservation, etc).
What is typically the best time to talk?
8-10am
10-12am
12-1pm
1-4pm
After 6:30pm
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