Cindy Baccarny Independent Optavia Health Coach
Cindy Baccarny cell- 910-918-0333
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you being treated by a Medical Professional for any of the following :
Gout
Type 1 Diabetes
Type 2 Diabetes
Thyroid Disease
High blood pressure
High Cholesterol
Heart Disease
Other
Do you have any food allergies or sensitivities? If yes , please list them .
Are you ??
Pregnant
Plan to become pregnant
Nursing
Premenopausal
Post menopausal
Rate the quality of your sleep .
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How many meals do you eat per day ?
Describe your exercise routine if you have one . (exercise is not necessary at the beginning of program. But this information will help me choose the appropriate plan for you . )
What is your approximate weight right now and how many pounds are you away from feeling confident ?
Describe any other weight loss programs that you have tried . I
Are you on a GLP-1 medication like Ozempic or Mounjaro? Are you interested in medically assisted weight loss?
On a scale of 1-5 , How committed are you to getting to your health goals ?
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Submit
Should be Empty: