New OptaHealth & Wellness Survey

~Get Healthy With Holden~

I'm so excited you're interested in taking your health to the next level. Please fill out the survey below and I will be in touch with you on the next steps to better health. ~Jennifer
First Name*
Last Name*
Email*
example@example.com
Date*

MonthDayYear
Today's Date
Address*
City*
State*
Two Letter Abreviation
Zip Code*
Phone Number*
Date of Birth

MonthDayYear
Date
Who referred you to us?*
If you were referred, name of person who referred you.
Areas of Interest and Current Level of Motivation...Discover where you are and where you want to be!
Right now, how much do you weigh and how tall are you? If you were like me and didn't get on the scale, how much do you think you weigh?*

0/330
Right now, how would you describe your overall health. Physical. mental, energy, SELF CONFIDENCE...
Why do you want to lose weight? What do you think will be different in your life when you get to a healthy weight (which you can!! Big boned is a lie we tell ourselves)?*

0/330
What would your DREAM health and weight goals look like?*

0/330
What would you change about your life right now to make it better? This is confidential! Dig Deep!! *

0/330
Background
Are you Pregnant?

NoYes
Are you Nursing?

NoYes
Do you have the following:

Diabetes - Type 1Diabetes - Type 2High Blood PressureGout
Are there any dietary restrictions you currently utilize? Please specify if you have a diagnosed food allergy.

0/160
Are you taking any medications for:

DiabetesHigh Blood PressureHigh CholesterolThyroid**Lithium*Coumadin (Warfarin)***
Are you taking other medications or have other medical conditions? Are you on a GLP-1, if so tell me how it is working? Side effects, weight loss?*

0/185
SLEEP
Rate the quality of your sleep.
HYDRATION
How much water do you drink each day?
What other beverages do you drink regularly?
MOTION
Do you exercise? If so how many times a week do you exercise?
EATING HABITS
How many meals do you eat a day?
What other programs have you tried. Oh BOY! I have tried them all! This is truly the best one!!
Do you have any questions for me?
Tell me the name of 1-2 people in your life who also need to get healthier. Friend, husband, kids, parent....
On a scale of 1-10, how committed are you to getting to your health goals?
I am 100% confident this program will work for you! It works for anyone who works it. You are the one variable to the program's success. It's simple, not always easy, but the things we want most in our life are not always the easiest. I know you can lose the weight that you want with my help, but with you being the variable, if you don't embrace the program and the process I can't guarantee your success. You may feel scared! it's scary to change and confront habits we have formed over the years! I was scared but I couldn't afford to not do this program 6 years ago! I am a better wife, mom, friend, and human because of the way I feel and the health that I created. There's only one person who can control your health and that person is you!!! I am so excited to work with you! Are you ready?
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~Get Healthy With Holden~