MyAtomicHealth

FIRST NAME
LAST NAME
Phone number
Time Zone
Age
Please share your date of birth if you are comfortable doing so.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How did you learn about the Program?
E-Mail
example@example.com
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Preferred Method of Contact
Awaken

Discover where you are and where you want to be!

Eating Habits
How many meals do you eat a day?
When do you eat your first meal?
When do you eat your last meal?
Do you snack between meals?
What kind of snacks?
How many times a week do you eat out?
Where do you typically eat out?
Most individuals spend between $15 and $25 a day food, where do you think you fall in this range?
Hydration
How much water do you drink each day? (one glass is typically 8 oz
How much of other beverages? Coffee
Tea (number of cups)
Soda (number of cans or bottles)
Do you drink alcohol, how often?

Motion
How would you rate your energy throughout the day?
What physical activities you enjoy?
How many times a week do you excercise?
Please tell me about anything you can't do right now that you would like to be able to do...

Surroundings
What do you feel is the biggest barrier/challenge you face with working on your health... what monsters/demons do we need to face down?
How healthy would you rate your surroundings? (Do you have healthy & active friends, supportive family, keep junk food in the house, etc.) 1=worst 10=fantastic
Research shows that people who work on building habits with others are 10x more likely to be successful. That's a great reason to have a coach. Is there anyone in your life who would like to get healthy with you?
Thank You for Completing the Survey, it would be my honor to assist you in achieving your goals!If you would like, use the calendar below to set up a time for us to connect!
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Awaken