Health and Lifestyle Snapshot

Health and Lifestyle Snapshot

With just a few quick weeks with us; you can feel better, look better and become more confident.
Tell us your Full Name 😊

First NameLast Name
E-mail
example@example.com
Best number to reach you on
Today's Date

MonthDayYear
Date
Your Current Age
How did you hear about me/us or our programs?
Right now, how much do you weigh and how tall are you? If you are like we were and don't really like to step on the scale, how much do you think you might weigh?
Right now, how would
Right now, how would you describe your overall health? (Physical, Mental, Emotional, Energy, Confidence, Fitness, etc...)
Why do you want to lose weight, gain muscle, change health habits? What do you think will be different in your life when you achieve your health and wellness goals?
What other things have you tried in the past to lose weight and / or develop a healthier life style? What other options are you considering right now?
What would your dream health/weight/activity goals look like?
What would you change about your life right now to make it better? We get some deep responses here so we want to ensure that you know that anything you share is totally confidential. We were on the other side of this question, struggling with medical afflictions, addictions and debt which was always a looming shadow before we started losing weight. We relied and hide behind excuses, medications, food and beverages to escape..... We get it, so share if you can.
BMI
Based on your height and weight right now, what is your current BMI number.
What is the BMI value for the weight you want to maintain at?
Medical
Are you currently taking any medications (Thyroid, Anxiety, Depression, Cholesterol, Blood Pressure, Diabetes or Off-Label Diabetic Injections, etc.)?
Are you currently being treated for any of the following?

GoutThyroid DiseaseHeart ComplicationsType 1 DiabetesType 2 DiabetesHigh Blood PressueHigh CholesterolOther
Are you.....

PregnantPre-MenopausalPost-MenopausalNursingN/A
Sleep
How is your quality of sleep and do you wake up feeling rested?
How many hours of sleep do you typically get?
What time do you typically wake up?
Hydration
How much water do you drink each day?
Do you consume any other beverages?

CoffeeSodaTeaAlcoholJuice (Apple, Orange, Fruit, etc)
Motion
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
Do you currently exercise? If so, how many times a week?
What physical / exercise activities do you participate in?
How would you describe your daily activity level?
If you are currently active or have an exercise regimen, do you take any type of supplements (Vitamins, Amino Acids, Protein Powder, Electrolytes, etc.)?
Stress
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Do you struggle with credit card debt, dealing with family financial issues? Believe us, we totally understand that overwhelming feeling and if you would like to hear more about what we did to get ahead of those struggles, we would be happy to share.
Are there any other stressors in your life (marriage issues, intimacy, relationships, struggles with divorce, parenting, family issues and resentment, narcissistic people surrounding you, etc..)? We get it. Before meeting each other, we both came from toxic divorce situations, so we understand the mental stresses these play in overall health, wellness and confidence.
Eating Habits
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
Additional Information
Current Weight: (if you want to share)
Height:
In a perfect world, if you could not fail, how many pounds would you want to lose to feel more confident.
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who would like to get healthy with you?
We are 100% confident in the programs we work with and their ability to work with everyone where they are currently at and where they want to get to. Literally, you are the only variable to these scientifically structured programs success. It is simple, not always easy, as with everything in life that truly matters, they aren't always easy. We know you can lose the weight, experience predictable transformation, gain healthy habits for a lifetime with our help, but with you being the only variable, if you fail, it is your fault.... If you succeed, it is your fault. BLUNT, we know, but how does this make you feel? Excited?, Scared?... GOOD, we were too! BUT, with our lives surrounded by variables we couldn't control, we were thrilled to take steps necessary to control the one variable we could with regards to our weight and health.. OURSELVES!!!! How do you feel now? Let's do this together. We are excited to work with you!
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you feel you learn better by:

ReadingDigital Media (podcasts, videos)
On a scale of 1 to 10, how ready are you to make changes to improve your health?

1

2

3

4

5

6

7

8

9

10

1 is Just thinking about it, 10 is Ready to do this
If you would like to schedule a follow-up call to further discuss your health goals and what programs might work best for you, please feel free to use this link to schedule a time.

Calendar to get your questions answered
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Health and Lifestyle Snapshot

BMI

Medical

Sleep

Hydration

Motion

Stress

Eating Habits

Additional Information