Stephanie Burgdofer - Optavia Independent Coach

the starting line...

Hi! I'm glad you are here! Please answer the below questions so we have a head start on helping you reach your goals! This experience will transform you from the inside out and has been on of the greatest blessings of my life! That is my hope and mission for you as well! Let's get started!
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Who referred you?*
If you were referred, please put the name of the person who referred you OR where you saw this link.
WHERE YOU ARE & WHERE YOU WANT TO BE

This section will give me a better idea of your current health and your health goals.
What is your current age?*
How much do you currently weigh? If you do not use a scale, how much do you think you weigh?*
What is your goal weight?*
How many pounds away are you from feeling confident again?*
What would you like to accomplish with your health? (select all that apply)*

Build MuscleImproved SleepGain EnergyBetter Response to StressReduce InflammationImproved Mindset around FoodOther
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.*

Diabetes Type IGluten Intolerance/AllergyDiabetes Type IISoy AllergyHigh Blood PressureFood AllergiesThyroidGoutCoumadin (Warfarin)NoneLithiumOther
Do you have any allergies or medical conditions not mentioned above that could influence the system we design for you?*
FOOD & HYDRATION
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? Include beverages, snacks, etc.*
The average American spends approx. $15-$20 a day/person on groceries, coffee/alcohol/beverages, supplements, snacks, dining out, etc. What would you guesstimate is your average cost on everything you put into your mouth daily?*

$10$15$20$25+
How many ounces of water do you drink per day?*
Do you drink other beverages, such as:*

SodaTeaWineAlcohol
How much alcohol do you consume daily/weekly/monthly?*
Do you have any food aversions - tastes, textures, etc.? Please list below.*
Do you prefer sweet foods, savory foods, or a blend of the two?*
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?*
How would you describe the quality of your sleep?*
On a scale of 1-10, what is your energy level throughout the day?*

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1 is HORRIBLE, 10 is EXCELLENT
Are there things you can't do that you would like to do?
How many days a week do you exercise? (0-7 days)*
Describe your workouts. Include length and types of workouts, i.e. cardio, weightlifting, etc.
Exercise is optional during the weight loss phase of the program I will design for you. Eventually, we will want to incorporate exercise to create optimal health. What types of physical activity do you enjoy in general? Think healthy movement over exercise.*
MINDSET

What and how we think about ourselves - our actions - and the everything in between!
Personality and Motivation: Do you consider your disciplined, organized and crave structure. Are you hard on yourself and see things balck/white....or are you laid back, flexible - seeing both sides and often looking for motivation from external sources? Do you have trouble staying on track or are you one to get instructions and go with it? Do you consider yourself confident, determined? If you know of the Enneagram-what number are you? If you don’t that’s ok!*
On a scale of 1-10, how fulfilled are you with where you are in your health & life currently?*

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1 is NOT AT ALL, 10 is VERY FULFILLED
Right now, how would you describe your overall health? Physical, mental, energy, self-confidence?*
On a scale of 1-10, how much do you worry about your health, family, finances and/or life in general?*

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1 is NOT AT ALL, 10 is ALL THE TIME
What area of your life tends to be most stressful?*
Do you work outside the home? Full-time/Part-time?*
On a scale of 1-10, how much do you enjoy what you do?*

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1 is I HATE IT, 10 is VERY HAPPY
Would you say you are more task-oriented or people-oriented?*
What is the hardest part of being you right now?
WEIGHT MANAGEMENT
Have you tried to reach these health goals in the past? If so, what have you tried? I tried several before I found this program!*
SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (Consider things like - do you have healthy and active friends, supportive family, a lot of junk food in the house, etc.)*

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Is there anyone in your life who you would like to get healthy with you?*
ARE YOU READY TO COMMIT TO YOURSELF?
This program has 4 components: Coaching, Community, Education, and Nutrition. You will utilize all 4 components equally. Each one is just as important as the other for reaching your health goals and maintaining your results long-term.

I am 100% confident in the program and its ability to work for EVERYONE who follows it's guidelines. This program isn't a diet. It's a LIFESTYLE. You will understand how your body and brain function optimally and how you will become your best YOU!

As you move through the program, you will become equipped with tools for life. Your relationship with food will become a healthy one! You will be empowered and you will become confident in your food choices...it's a great feeling!

As your coach, I will be your cheerleader, your confidant, your encourager and your reference throughout the days and weeks to come. We will move mountains together and we will celebrate!

I'm excited for the opportunity to get to know you - thank you in advance for trusting me with this decision!

We'll talk soon!

Susan
On a scale of 1-10, how committed are you to getting to your health goals?

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1 is I'M NOT READY, 10 is READY YESTERDAY
Additional comments you want me to know:
Should be Empty:

the starting line...

WHERE YOU ARE & WHERE YOU WANT TO BE

FOOD & HYDRATION

SLEEP & ENERGY

MINDSET

WEIGHT MANAGEMENT

SURROUNDINGS

ARE YOU READY TO COMMIT TO YOURSELF?