Free Wellness Survey
These quick questions will help us understand what brings you here and whether a targeted metabolic reset may be a fit for you.
Please tell us a little about you
Name
*
First Name
Last Name
Today's date
.
Month
.
Day
Year
Date
E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number
Preferred method of contact
*
Phone
Text
Email
Have you taken the Metabolic Health quiz yet?
Please Select
Yes
No
https://forms.fillout.com/t/uqwe5JVihBus
Your Vision & Your Why
How would you describe your perfect day in your healthiest, strongest, most confident body? Can you please describe it like a movie?
What part of that picture is missing for you right now?
What would change first for you, your family, or your loved ones if you got that missing piece back?
Your Current Metabolic Symptoms
Please check all that apply
Which of these currently apply to you?
*
Fatigue or low energy
Poor digestion or bloating
Mood swings or irritability
Difficulty sleeping
Excess fat accumulation, particularly around waist
Sugar cravings
Brain fog/lack of mental clarity/difficulty concentrating
Slow metabolism
Hormonal imbalances
Frequent hunger or overeating
Other
If other, please add:
On a scale 1-5, how out of sync does your metabolism feel?
*
Thriving
1
2
3
4
SOS Help!
5
1 is Thriving, 5 is SOS Help!
What have you tried so far to fix these symptoms?
*
Diet changes
Exercise
Supplements/vitamins
Detoxes
Medications
Therapies or coaching
Wearables/trackable devices
None
Other
Why do you think those approaches didn't work long term?
How are your current metabolic symptoms affecting your life right now?
*
Reduced energy or lack of vitality
Low motivation
Negative impact on relationships
Decreased productivity
Mental health challenges
Social withdrawal
Physical discomfort or pain
Unable or unwilling to engage in activities that bring you joy or fulfillment
Financial stress
Other
If everything stays the same, where do you see yourself in the next 6-12 months? What is the sequel to the movie about your current situation?
*
What results are you looking for?
What areas would you like to see improvement?
*
Increased energy and vitality
Improved productivity
Weight
Body composition (increase lean muscle and decrease body fat)
Mental clarity and focus
Better sleep quality
Emotional balance
Long-term health
Improved outlook
Other
What support do you feel would be most helpful?
*
Accountability coaching
Personalized meal plans
Healthy motion/exercise guidance
Mindset/motivation
Stress management
Community support
Other
What currents habits or patterns are holding you back?
Are you ready for a targeted metabolic reset?
If there were a proven path that could reset your metabolism, help you burn fat, protect 98% of lean body mass, and reverses metabolic dysfunction, how open to you are following that path?
*
Not open or ready
1
2
3
4
Very open and ready to go!
5
1 is Not open or ready , 5 is Very open and ready to go!
Are you prepared to invest in your health?
Please Select
Yes
Yes and need details
Not right now
If accepted into the program, how soon would you like to start?
Please Select
Right away - I need a positive change!
Soon - in a week or so
I need some time
We know our targeted metabolic reset works and can set you on the path to health, if followed properly. Is there anything else you'd like to share so we have a fuller picture before we review your application?
I consent to receive SMS notifications/alerts and occasional emails. Message frequency varies. Message and data rates may apply. You can opt out of SMS/emails at any time.
Yes
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