Your Metabolic Health Profile
Let’s find the right plan for you!
Today's Date
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Month
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Day
Year
Date
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.
Email
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example@example.com
What would you like to accomplish with your health? (select all that apply)
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Weight Loss
Weight Gain
Build Muscle
Improved Sleep
Gain Energy
Better Response to Stress
Reduce Inflammation
Other
Are you pregnant?
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Yes
No
Are you nursing?
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Yes
No
Do you have any allergies or medical conditions that could influence the plan we customize for you?
What are your taste preferences?
Chocolate
Vanilla
Strawberry
Peanut butter
Lemon
Chocolate Mint
Cinnamon
Soups
Pastas
Chocolate chip cookies
Brownie
Pudding
BBQ
Caramel
Oatmeal
Pancakes
Mashed Potatoes
Coffee flavors
Other
What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc
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How many hours of sleep do you get in a typical night?
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How many meals and snacks do you eat per day?
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How many times a week do you eat out? And where? Include beverages, snacks, etc.
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The average American spends approx. $15-$20 a day/person on groceries, beverages, supplements, snacks, dining out, etc. What would you guesstimate is your average?
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$10
$15
$20
$25+
How many ounces of water do you drink per day?
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Do you drink other beverages, such as:
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Coffee
Soda
Tea
Wine
Alcohol
How many cups of coffee? Do you add anything to it? (creamer, etc)
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How much soda/ice tea/energy drinks/other non-alcoholic beverages daily?
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How much alcohol weekly or monthly do you consume? What are your drinks of choice?
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What is your current age?
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Are you at your ideal weight? If not, how much weight would you like to lose or gain?
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Have you tried to reach these health goals in the past? If so, what have you tried?
Additional comments you want me to know:
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