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.
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?
*
< $10
$10-15
$15-20
$20+
Current Health
Age
*
Height
*
Weight
*
Do any of these apply to you? (select all that apply)
*
None
Gluten intolerance/allergy
Celiac
High Blood Pressue
Thyroid
Coumadin (Warfarin)
Diabetes Type I
Diabetes Type II
Soy Allergy
Food Allergies
Gout
Medically Supported Weight Loss Drug/GLP-1
Are you pregnant or nursing?
Yes
No
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?
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Less than 4 hours
5-6 hours
7-8 hours
8+ hours
How would you rate the quality of your sleep on a scale of 1 to 10?
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Horrible
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Horrible, 10 is Excellent
On a scale 1-10, how would you rate your energy level
*
Thriving
1
2
3
4
5
6
7
8
9
SOS
10
1 is Thriving, 10 is SOS
How much water do you drink daily?
*
Less than 20 ozs.
20-40 ozs.
40-60 ozs.
60-80 ozs.
80-100 ozs.
100+ ozs.
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
I would love to hear what you would like to accomplish with your health. Please select all that apply
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Weight loss
Weight gain
Gain energy
Better response to stress
Improve sleep
Reduced inflammation
Improve your relationship with food
Reduce cholesterol levels/medication
Lower high blood pressure
Reduce A1C levels/diabetes management/medication
Prepare or recover more effectively from surgery
Reach ultra health
Peri/Menopause management
Other
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?
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Fatigue or low energy
Difficulty losing weight
Poor digestion/bloating/gut issues
Mood swings or irritability
Sleep problems
Sugar cravings
Brain fog or difficulty concentrating
Slow metabolism
Hormonal imbalances
Frequent hunger or overeating
Skin tags
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?
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Very open and committed
Not sure yet
Are you prepared to invest time, energy, and money into your health if the plan fits you?
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Yes
Not right now
How soon would you want to start?
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Right away
This week
Within the next two weeks
COMMITMENT LEVEL: On a scale of 1-10, how committed are you to making lasting changes in your health?
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Not so sure
1
2
3
4
5
6
7
8
9
Let's do this!
10
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?
*
| Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.
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Yes
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.
*
Yes
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