Metabolic Health Questionnaire

Is your metabolism working with you or against you?

Your body is always communicating through energy, cravings, sleep, stress, and weight.This questionnaire helps us identify patterns in your metabolic health so we can address root causes—not just symptoms.There are no right or wrong answers—just answer honestly so we can determine the best next steps for you……Take a few minutes to watch this video on metabolic health and its relevance in today’s demanding culture.
Fill this out for a chance to win the Metabolic scale: Get your Metabolic Score here!
Tell me about you
First and Last Name
Email
example@example.com
Phone
What do you do for work; Describe your level of activity....Are you mostly Sedentary or Very Active?
What does a typical day of eating look like for you including beverages - Starbucks, alcohol, anything that goes in your mouth. Please include when you have your first meal of the day and how many times you eat throughout the day.
How much alcohol/sodas/sweet tea/coffee w sweeteners do you consume daily/weekly? If alcohol, What is your alcohol drink of choice?
On average, how much do you spend on food and beverage each day on avg?
Current Health
Age
Height
Weight
Do any of these apply to you? (select all that apply)
Are you pregnant or nursing?
I would love to hear what you would like to accomplish with your health. Please select all that apply

Other
Describe your most common sources of worry or stress. How do they affect your daily life?
How many hours of sleep do you get on average each night?
How would you rate the quality of your sleep on a scale of 1 to 10?

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1 is Horrible, 10 is Excellent
On a scale 1-10, how would you rate your energy level

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1 is Thriving, 10 is SOS
How much water do you drink daily?
What, if any, type of exercise do you do currently? Describe the frequency and intensity.
Are you currently taking a GLP1 or interested?
Your Vision + Your Why
What is your main motivation for wanting to make changes to your health? (Relationships, activities, energy, confidence, etc.)
Your Current Metabolic Symptoms
Which of these describe you right now?

Other
Are You Ready for a True Metabolic Reset?
If there was a proven path that burns fat, protects 98% of your lean muscle, and reverses metabolic dysfunction, how open are you to following it exactly as designed?
Are you prepared to invest time, energy, and money into your health if the plan fits you?
How soon would you want to start?
COMMITMENT LEVEL: On a scale of 1-10, how committed are you to making lasting changes in your health?

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1 is Not so sure, 10 is Let's do this!
Is there anyone else in your life who would like to get healthy with you? It is so much fun to get fit with a friend of family member and surround yourself with a healthy community!
Anything else you want me to know?
Do you currently follow a structured nutrition plan or are you interested in learning how a simple, effective nutrition plan could help support a healthy metabolism?
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This program is not to diagnosis, treat or cure medical conditions. Simply designed to support metabolic health and should compliment, not replace, your medical care.
Sign up for a 15-minute phone or zoom appointment to chat with Coach Shannon by clicking here.
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Is your metabolism working with you or against you?

Tell me about you

Current Health

Your Vision + Your Why

Your Current Metabolic Symptoms

Are You Ready for a True Metabolic Reset?