Healthier in 30 DAYS!
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Full Name
First Name
Last Name
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
What is your weight, age, and heights?
What is your gender?
Please Select
Male
Female
N/A
Rate your quality of sleep.
How many meals do you eat daily?
Scale of 1-10 How committed are you to getting your health goals going?
How many other weight loss programs have you tried? Heaven knows we have all tried several in our lifetime. Nothing to be ashamed of!
Are you being treated for any of the following?
Gout
High Cholesterol
Thyroid Disease
Diabetes Type 1
Hypertension High Blood Pressure
Diabetes Type 2
Auto Immune Disease
Other
Check all that apply:
Blood Sugar 100+
Blood Pressure High
Triglicerides 150+
Blood Pressure Low
Male Waist over 35
Low HDL
Weight gain
Female waist over 40
Do you exercise?
Yes
No
Why do you want to lose weight? What do you think will be different in your life at a healthier weight?
What would your dream health and weight goals look like? Be specific.
Would you be interested in personal training?
Yes
No
Not Sure
What would you change in your life to make it better? This is all highly confidential and people get pretty deep here. We are in this together.
How would you describe your overall health? Physical, mental, energy, self confidence?
Do you have troubles in your relationship or marriage right now? Resentment? Infidelity? No romance? Trust Issues? Are you roommates? The fear of not facing these things will keep you paralyzed and I do not want anyone to feel that way. You are not alone!
Do you struggle with a narcissist, addict, or borderline personality disordered person in your life?
Do you ever experience anxiety? Agoraphopia? Control Issues? Healing needs to be intentional.
Is your family in credit card debt? Do you worry about finances?
Do you have a health coach?
Do you have a personal trainer?
Would you like a FREE 15 minute Coaching Call to help you START your 30 Days to a Healthier Lifelong Journey? If yes, please make sure you fill out the contact information above.? Yes, No or Unsure
Do you struggle with a narcissist, addict, or borderline personality disordered person in your life?
Are you Pregnant, Nursing, Pre/Post Menopause?
Please Select
Pregnant
Nursing
Pre Menopause
Post Menopause
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
I know these questions can feel very personal — I’ve been there myself. The first time I filled one out, it felt uncomfortable… but it completely changed my life. That’s why I’m so excited for you — because this is your moment to take action.You’ve already made the decision to do something different, and that’s huge. Now it’s time to follow through. If you’re truly ready to make a change and commit to this process, you will see incredible results — not just in your health, but in every area of your life.Let’s get started today — your future self will thank you.?
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