TransformwithMe

Thank you for reaching out!

I’d love to learn more about you and your health goals. Please answer the following questions before we chat.
Name*

First NameLast Name
Phone Number*
Email*
Age*
Height*
Current Weight*
Goal Weight*
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
How do you prefer to be contacted?
What is your MAIN motivation for wanting to make changes to your health? (Relationships, activities, how you feel, etc)*
What would you like to accomplish with your health? (Weight loss, improved sleep, better response to stress, etc)*
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?*
Are you currently pregnant?

YesNo
Are you taking any medications for:

High Blood PressureDiabetesThyroidFood or other allergiesOther
How many hours of sleep do you typically get?
Do you wake up feeling rested?
About how many ounces of water do you drink daily?
What other drinks do you have daily?
How would you rate your energy level? (on a scale of 1-10)
Do you currently exercise, and if so, how many times a week?
How many meals per day do you eat?
When do you eat your first meal?
Do you snack between meals?
How many times a week do you eat out?
What has been most difficult about losing/maintaining weight in the past?
How healthy would you rate your surroundings? (On a scale of 1-10)
Do you have healthy & active friends, supportive family, keep junk food in the house, etc.
Is there anyone in your life who would like to get healthy with you?
Thank you for your thoughful and honest answers regarding your current habits. Habit building is the key to long term success. I appreciate you taking the time to complete this form and would love to chat with you further to recommend which program would be the best fit for you.
After submitting this form, you will receive a link to schedule a call on my calendar. I look forward to connecting with you and helping you on your healthy and wellness journey.
-Elizabeth Blanchard
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Thank you for reaching out!