Fhysical Elements Health

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Let's get to know you...
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
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What time zone are you currently in?
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Pacific
Mountain
Central
Eastern
Alaska
Hawaii
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What is your height? (Ft/in)
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What is your current weight? (lbs)
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Describe your current health...are you struggling with an illness?
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Please list any medications you are currently taking and their purpose:
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Do you have any food allergies or restrictions?
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Where would you like to be in your health?If you could not fail, what does your ideal health look like? If you desire weight loss, how much weight would you like to lose?
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What is making it difficult to accomplish your health goals?
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What is your motivation for wanting to change now?What's your WHY?
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Do you get a good night sleep?
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Please Select
Yes, I get adequate sleep and feel well rested
Toss and Turn
Up throughout the night
Wake up tired
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What do you do for a living?Are you sedentary or active?
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Describe your activity level?
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Please Select
Do not exercise
Exercise by walking or low impact activities (occasionally)
Exercise daily, high impact or heavy lifting
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On a scale of 1-10, rate your stress level 1 = low 10 = off the charts high
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On a scale of 1-10, rate your energy 1 = dragging 10 = energizer bunny
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How much plain water do you drink a day?
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Please Select
Less than 32 oz
32-64 oz
More than 64 oz
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What other drinks do you routinely enjoy?
Coffee, black
Beer, wine, alcohol
Tea
Milk
Soda
Juice
Other
Coffee with creamer
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Eating Habits
How many meals per day do you eat?
Do you snack?
What kind of snacks?
How many times a week do you eat out?
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Is there anyone in your life who might want to do this with you?
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On a scale of 1-10, how ready are you to make a Lifestyle Change to accomplish your health goals and live in Optimal Health?1 = just considering it, 10 = desperate and so ready!!!
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Are you on Facebook? Find me as Brady Worster, to see my journey!
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Were you referred by a friend or family member? If so, who can I thank for sending you my way?
Referred by
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Thank you for taking the time to share your goals with me! I am thrilled to partner with you as you begin your journey to optimal health. Feel free to add anything you want me to know
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