The Empowerment Zone Health and Wellness Questionnaire
The purpose of this questionnaire is to determine how best to assist you with meeting your health and wellness goals. Please review your answers carefully before submitting your application. Once you submit this form, you will not be able to change your answers. After you submit your questionnaire, check your e-mail for information on the program best suited for you based on your answers.
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Name *
Email Address *
Phone Number
We should probably schedule a call to talk about your goals. Feel free to leave your number and a time that is good for you.
Why did you decide to get help with your health and wellness? Check all that apply *
Required
Besides losing weight, what is the one thing you would like to have successfully accomplished during your wellness journey?   *
Besides the answers you provided in the previous question, what other reason(s) do you have for wanting to get healthy, lose weight and/or receive motivation and support ? *
Feel free to use as many words as possible to express why you are taking this challenge at this time.
Are you currently exercising on a regular basis?  If yes, what are you doing (running, aerobics, strength training, etc.)? *
Can you commit to working out 3-5 days a week? *
Answering "No" to this question doesn't necessarily disqualify your application.
Can you commit to a meal plan and improving your eating habits? *
Answering "No" to this question doesn't necessarily disqualify your application.
Are you currently working with a BODi Partner? *
Are you a BODi Partner/Affiliate? *
Would you like to learn more about becoming a BODi Partner/Affiliate?
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