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Online Wellness Evaluation Form
Lets talk about your ultimate fitness goals!
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1
E-mail
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2
Full Name
First Name
Last Name
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3
Phone Number
Area Code
Phone Number
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4
Birth Date
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Month
Day
Year
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5
Height (feet/inches)
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6
Weight (pounds)
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7
How much weight do you want to LOSE/GAIN?
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8
Why do you want to LOSE/GAIN this weight?
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9
What other programs/products have you tried in the past?
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10
What is your biggest struggle when trying to LOSE/GAIN weight?
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11
How many times a day do you eat?
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12
Which meal do you usually skip?
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13
If yes, at what time do you have a snack attack? Daytime / Evening
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14
What is your favorite snack?
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15
How much do you spend on food per week?
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16
Where do you carry most of your unwanted weight?
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17
Do you have cellulite that you want to get rid of?
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18
Do you take vitamins or any type of nutritional supplements currently?
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19
How many CUPS / OUNCES of water do you drink daily?
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20
Do you eat out? How often? (Times/week)
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21
Where is your energy level, on a scale of 1 to 10? (1: Dragging / 10: Bouncing)
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22
Are you currently taking any prescription medication?
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23
Do you regularly exercise? If YES, what type and how often?
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24
Check all HEALTH CONDITIONS that apply to you:
Acne
Alcohol Consumption
Allergies
Alzheimer's Disease
Anemia
Anxiety
Arthritis
Asthma
Back Pain
Bladder Infection
High Blood Pressure
Caffeine Consumption
Caffeine Sensitivity
Calcium Deficiency
Cancer
Celiac Disease
Chronic Constipation
Chronic Fatigue
Chronic Sinusitis
Circulation (poor)
Colitis
Congestive Heart
Failure
Depression
Diabetes Type One
Fibromyalgia
Gall Bladder Disease
Gall Stones
Gout
Heartburn
Heart Disease
Hernia
High Cholesterol
Hyperactive
Hypoglycemia
Insomnia
Irritable Bowel Syndrome
Kidney Disease
Kidney Stones
Low Energy
Low Sexual Stamina
Lupus
Menopausal
Migraine Headaches
Mood Swings
Multiple Sclerosis
Nursing Mother
Pregnant
Premenstrual Syndrome
Osteoporosis
Sleep Disorder
Smoking
Stress
High Triglycerides
Water Retention/Bloating
Ulcers
Diabetes Type Two
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25
What time do you usually wake up?
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26
BREAKFAST (Eat & Drink)
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27
AM SNACK (Eat & Drink)
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28
LUNCH (Eat & Drink)
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29
PM SNACK (Eat & Drink)
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30
DINNER (Eat & Drink)
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31
EVENING (Eat & Drink)
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32
GOALS: WHY do you want to accomplish this? Be as SPECIFIC, DETAILED, and VAIN as possible. How do you want your body to look and feel? Which model, actor/actress, or anyone do you want your body to look like? Do you want more confidence? Do you want to be secure in your own body? Really think about this thoroughly.
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33
Once you got results, are you open to the business opportunity?
YES
NO
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34
How do you appear on IG?
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35
Type a question
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36
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