Full Name
*
First Name
Last Name
E-mail
example@example.com
Best number to reach you on
Format: (000) 000-0000.
Date of birth
-
Month
-
Day
Year
Date
Age
How did you hear about me or our programs?
Please describe WHY you are interested in getting healthy. (What is your main motivation? Relationships, activities, how you feel, etc)
For learning purposes do you prefer to read printed text or listen to audiobooks?
Print
Audio
Typical Day
BMI
Based on your height and weight right now, what is your current BMI number?
What is the BMI value for the weight you would like to maintain?
What time do you typically wake up?
How many hours of sleep do you typically get?
How is your quality of sleep and do you wake up feeling rested?
Hydration
How much water do you drink each day?
Do you consume any other beverages?
Coffee
Soda
Tea
Alcohol
Juice (Apple, Orange, Fruit, etc.)
Motion
What do you do for work?
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?
How would you describe your daily activity level?
Please Select
Sedentary
On your feet
Active
Stress
How would you rate your stress level on a scale of 1-10?
Are there any other stressors in your life?
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)
Weight
Current Weight: (if you want to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
Height:
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?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is there anything else I should know about your current health journey?
Submit
On a scal of 1 to 10, how ready are you to make changes to improve your health?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Should be Empty: