Your Wellness Survey

Your Wellness Survey

I'm so excited you're interested in taking your health to the next level! Please fill out the survey below and I will be in touch with you on the next steps to better health. -Michelle Fields
Name*

First NameLast Name
Email*
example@example.com
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
How did you hear about me?*
Preferred Method of Contact*

TextCall
Have you previously been on Optavia?
If so, when and what happened?
If so, who was your coach?
Where You Are Now
Describe why you are interested in getting healthy.
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?
Background
Do you have any of the following?

Diabetes- Type 1Diabetes- Type 2High Blood pressureGout
Are you taking any medications for:

DiabetesHigh Blood PressureHigh CholesterolThyroidLithiumCoumadin (Warfarin)Depression medsGLP1 or off-label diabetes injections
Are there any dietary restrictions you currently utilize? Please specify if you have a diagnosed food allergy.*
Are you taking other medications or have other medical conditions that could influence which program we choose?
Are you...

PregnantNursingPre-menopausePost-menopause
Hydration
How much water do you drink each day?*
Motion
How would you rate your energy level? (on a scale of 1-10)
How many times a week do you exercise?
Mind
How would you rate your stress level? (on a scale of 1-10)
What do you do for work?
How much do you enjoy what you do?
When and where was your last vacation?
Do you worry about your finances?

YesSometimesNo
Eating Habits
How many meals per day do you eat?
Do you snack between meals?
What kind of snacks?
How many times a week do you eat out?
Weight
Current Weight
Height
Goal Weight
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?
What other weight loss programs or "fixes" have you tried? (Please also include any surgeries or medications for weight loss)
On a scale of 1-10, how committed are you to getting to your health goals?
Surroundings
Do you have healthy & active friends, supportive family, keep junk food in the house, etc?
Is there anyone in your life who would like to get healthy with you?
Are you currently on a GLP1 medication for medically-supported weight loss?

YesNo
If you have ever before or currently use medically-supported weight loss, please describe your experience:
Optavia has partnered with LifeMD to provide options for medically-supported weight loss. Our goal is to provide the medical tools people need to be successful among with the education, accountability, community, and convenience they need to create lifelong habits.

Working with LifeMD includes contact with a nurse practitioner for your prescription, weight loss guidance, and daily and urgent care support. Pairing medically supported weight loss with our customized plans gives you a one-on-one coach for habit health, nutrition guidance, and a healthy community to create optimal conditions for healthy, sustainable weight loss that protects your muscle mass. There are several affordable options.
Yes, I am interested and would like more informationNo, I'm not interested at this timeI know someone who may be interestedI'm curious to hear more
Please drop the link to your Facebook or Instagram if you have one!
Should be Empty:

Your Wellness Survey

Where You Are Now

Background

Hydration

Motion

Mind

Eating Habits

Weight

Surroundings