Health Questionnaire

I lived the Change - Now I Coach it Forward

Welcome! I'm excited to join you on your journey to health! These questions help me understand what brings you here and whether this reset may be a strong fit for you. Answer what you feel comfortable with.

Let's get started!

Tell me more about yourself

First Name

Last Name

example@example.com

Phone Number

Please enter a valid phone number.

Time Zone

Eastern

Central

Mountain

Pacific

Do you wish to Lose, Gain or Maintain weight?

Lose Weight

Gain Weight

Maintain Weight

How much weight do you want to Lose/Gain?

Describe your current health... are you struggling with an illness? Do you have any dietary restrictions or food allergies?

Please list any medications you are currently taking:

Which of these describe you right now?

Difficulty losing weight

Difficulty gaining weight

Poor digestion or bloating

Mood Swings or irritability

Sleep problems

Sugar cravings

Brain fog or difficulty focusing

Slow metabolism

Hormonal imbalances

Frequent hunger or overeating

Other

Where would you like to be in your health? If you could not fail, what does your ideal health look like?

What have you tried so far to fix this?

Diet Changes (Self Supervised)

Exercise Routines

Supplements & Vitamins

Detox Programs

Medication

Therapies or coaching

Fad diets

Weight Watchers

None

Other

Why do you think those things did not work?

How is this struggle affecting your life right now?

Reduced energy & motivation

Impact on family relationships

Work productivity decline

Mental health challenges (depression)

Social withdrawal

Financial stress

Other

Do you get a good night sleep?

What do you do for a living? (Are you sedentary or active?)

Describe your activity level:

Do not exercise

Exercise by walking or low impact activities (occasionally)

Exercise daily, high impact or heavy lifting

On a scale of 1 - 10, rate your stress level 1 = low 10 = off the charts high

On a scale of 1 - 10, rate your energy 1 = dragging 10 = Energizer Bunny

How much Plain Water do you drink a day?

Less than 32 oz

32 - 64 oz

More than 64 oz

What other drinks do you routinely enjoy?

Coffee, black

Tea

Soda

Beer, Wine, Alcohol

Milk

Juice

Coffee with creamer/sugar

Other

How many meals per day do you eat?

What kind of snacks?

How many times a week do you eat out?

What type of restaurants?

Is there anyone in your life who might want to do this with you?

What results are you hoping for?What matters most to you right now?

Improved energy & vitality

Fat loss & body composition

Mental clarity & focus

Better sleep quality

Emotional balance

Long term health and longevity

Other

What support do you feel you need most to follow through?

Accountability coaching

Personalized Meal plans

Excercise Guidance

Mindset & Motivation Support

Stress Management Techniques

Community Support

Other

What current habits or patterns hold you back most?

If there was a proven path that burns fat, protects 98% of your lean muscle mass, and reverses Metabolic Dysfunction, how open are you to following is exactly as designed?

Very open & commited

Somewhat open, need m ore info

Not sure yet

Not open at all

Are you prepared to invest time, energy and money into your health IF the plan fits you?

Yes

Yes, but need details

Not right now

If accepted, how soon would you want to start?

Right away

This week

Within the next 2 weeks

Is there anything else you would like me to know before I review your application?

https://www.facebook.com/brenda.j.hall.5?

1 year apartActual age 63 - Metabolic Age reduced to 60 🪂