Wellness Evaluation
Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
What are your top wellness goals? (Check all that apply)
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Weight loss
Fat loss/ toning
More energy
Better digestion/ gut health
Muscle building
Stress management
Heart health/ cholesterol support
General health & consistency
If you could change ONE thing about how you feel daily, what would it be?
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How would you describe your current eating habits?
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Very consistent & balanced
Somewhat consistent
All over the place
I skip meals often
I rely on convenience/ fast food
How much protein are you getting in daily?
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Which meals do you struggle with most?
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Breakfast
Lunch
Dinner
Snacks
Late night eating
How often are you getting in movement?
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0-1 days/week
2-3 days/week
4-5 days/week
6-7 days/week
What does your movement usually look like?
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Walking
Strength training
Cardio classes
At home workouts
Sports/Active Job
None right now
Biggest barrier to movement right now?
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Time
Energy
Motivation
Injuries/Limitations
Not sure where to start
What do you feel you need the most help with to reach your goals? (Choose all that apply)
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Consistency
Accountability
Meal structure
Protein intake
Energy & Focus
Education
Have you ever followed a nutrition plan before? If yes, what plan and how did it go?
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What monthly investment feels comfortable for you right now? Coaching, Nutrition Guides, Products, Workouts, Accountability
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$100-$150
$150-$200
$200-$250
I’m not sure yet
What are you most interested in right now?
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21 day accountability challenge
Weekly Weigh Ins & Coaching
Customized nutrition plan
Healthy swaps
One a scale of 1-10, how ready are you to make changes right now?
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Submit
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