Samantha's Health Journey Assessment
This is the first step in taking your life back. Dream Big, Stay Focused, and MAKE IT HAPPEN!
Tell me your Full Name :)
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What would you like to accomplish in your health? (select all that apply)*
Right now, how much do you weigh? Or, how much do you think you weigh?
Right now, how would you describe your overall health? Physical, mental, energy, self confidence..
Why do you want to lose weight? What do you think will be different in your life when you get to a healthy weight. How will you show up differently, in your family, at your work, in pictures??? (Before I got healthy I used to avoid pictures if possible)
What would your dream health/weight goals look like? Give me your dream goals!
What would you change about your life right now to make it better? I get some deep responses here and I want you to know this is totally confidential. I knew my relationship with my kids and husband were struggling before I started losing weight and I knew my anxiety was out of control. Both were big reasons I overate, so I get it. Share away...
What is your "vice" mine was sweets and pasta. (AKA unhealthy ways to numb out or cope with my emotions)
Rate the quality of your sleep between 1-10 (1 being horrible sleeping patterns and tired all the time - 10 being 8 hours of amazing sleep waking up feeling rested)
Do you exercise? If so what are you doing?
How many pounds away are you from feeling confident?
On a scale of 1-10, how committed are you to getting to your health goals?
I am 100% confident in the program and its ability to work for everyone. Literally, you are the only variable to the programs success. Its simple, not always easy, but the things that matter in life are never easy. I know you can lose the weight you want with my help, but with you being the only variable, if you fail, its your fault, if you succeed its also your fault. How does that make you feel? Scared? Good! I was too. BUT, my life was in shambles because of all the things I could NOT control. I decided to be excited that I could control one part of my life. How do you feel now? I am so excited to work with you!
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