Healthy Ripples

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Hi there! We are Kyle & Allie Robbins

Hi there! We are Kyle & Allie Robbins

Welcome to our Health Questionnaire. If you have goals to improve your health in any area, please fill out and submit this form. We will reach out to share a plan that may fit your health goals as soon as possible!

21Questions

1
Name
First Name
Last Name
2
I would love to know how you found me!?Social, Friend or Family, Advertisement
3
Are you looking for...Select all the apply
Weight loss
Optimal Health with quality Nutrition
Ultra Health to support strong activity levels
Nutrition support while on medically supported weight loss
Other
4
Describe your current health...are you on any medications, struggling with an illness?Medication? Diabetes? Thyroid? Etc?
Huge
Large
Normal
Small
Ok
Ok
5
Do you have any food allergies or sensitivities I should be aware of?
Huge
Large
Normal
Small
Ok
Ok
6
Where would you like to be in your health?If you could not fail, what does your ideal health look like? If a weight loss goal, how much weight would you like to lose?
Huge
Large
Normal
Small
Ok
Ok
7
What is making it difficult to accomplish your health goals?
8
What's your motivation for wanting to change now?What's your WHY?
9
What have you tried in the past or are considering to reach your goals?Various Diets and/or Medically Supported Weight Loss, Workout
10
How's Your Sleep?
Great
Up through the night
Toss & Turn
Not at all
Take medicine to help sleep
11
What do you do for a living?Are you sedentary or active?
12
What is your activity level during the day?Up and moving around?
Please Select
Please Select
Low
Moderate
High
13
Do you currently exercise, if so what do you do and how many times a week?
14
Describe your stress level;1 = low 10 = off the charts high
15
On a scale of 1-10, rate your energy throughout the day.1 = dragging 10 = energizer bunny
16
How much plain water do you drink a day?
Less than 64 oz
More than 64oz
17
What else do you drink?select all that apply
Coffee
Beer, wine, alcohol
Tea
Energy Drinks
Soda
Milk or Juice
Other
18
What are your eating habits?
How many meals do you eat daily?
What do you snack on?
How often do you eat out
19
Thank you for sharing with me! Now it's time to set up a quick call to select the exact plan that will best fit your health goals!What is the best number to reach you?
Please enter a valid phone number.
20
Email
example@example.com
21
Did someone refer you? If so, who?
Should be Empty:

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