Name
First Name
Last Name
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Email
example@example.com
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Which option best describes you?
I feel normal, but want to feel amazing. I need to fine-tune.
I feel awful. I need help and am willing to do just about anything to feel better.
I feel pretty good, but I want to learn. more. I need a little guidance and education on what I can do to get where I want to be.
Which option best describes you?
The thought of giving something up forever makes me feel anxious/panicked
I am not often tempted by things that I have made the decision are "off-limits".
Which option best describes you?
An occasional indulgence gives you the satisfaction and/or strength to continue on with your goals.
Once I start something, I can't stop, and it becomes a vicious cycle.
Which option best describes you?
I am very self-motivated; once I put my mind to something, nothing can stop me.
I need another individual to motivate me, someone, who will hold me accountable.
I am very motivated in group settings where others are working towards the same goal with me.
I don't know what motivates me, I have never completed a goal I set for myself.
List 3-5 things you feel you are doing well when it comes to your health.
LIST the top 3-5 things you are looking to improve in your life.
Has a physician diagnosed you with any illnesses? (ex: high BP, PCOS, cancer, IBS, etc.)
Do you currently take any medications and/or supplements? (if so please list)
Is there anything else you would like to share about yourself or your journey?
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