BellaBody Wellness Evaluation
Complete & submit within 48 hours of purchasing program.  Form must be submitted prior to first session.
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Email *
Date *
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First Name: *
Last Name: *
Age: *
Birthdate *
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Street Address: *
City: *
State: *
Zip: *
What are your health & wellness goals? *
Current Weight: *
Goal Weight:   *
Height (Feet and Inches) *
How much weight do you want to lose? *
Have you been on a diet/weight loss program in the last 12 months? *
If yes, which one and what were your results?
Do you eat at least three meals a day? *
If no, which meals do you skip?
What do you have for breakfast? *
Do you have a problem with snacking? *
If yes, what time of the day?
Do you take vitamins or any type of nutritional supplements? *
If yes, name type and purpose?  
Daily Water Intake (oz) or (cups) *
How often do you eat out? *
Where is your energy level on a scale of 1 to 10? *
Low Energy
High Energy
Are you currently taking any prescription medications? *
If yes, for what?
Are you allergic to any foods? *
If yes, what foods?
Do you feel hungry soon after eating a large meal? *
Do you suffer from frequent fatigue and loss of energy? *
Do you sometimes suffer from constipation? *
Do you exercise fewer than 3 times per week? *
Do you eat late at night? *
Do you eat a lot of meat or dairy? *
Do you crave breads and/or sweets? *
Do you suffer from gas or indigestion? *
Starting Measurements - Upper Right Arm - inches *
Starting Measurements - Upper Left Arm - inches *
Starting Measurements - Left Thigh- inches *
Starting Measurements - Right Thigh- inches *
Starting Measurements - Bust/Chest- inches *
Starting Measurements - Waist - inches *
Starting Measurements - Hips - inches *
Tell me your story.  What were your reasons for joining this program and what is your WHY?  Be specific. *
INFORMED CONSENT: I would like to take this opportunity to welcome you to the BellaBody Reset program. I am a Holistic Health Practitioner, not a medical or naturopathic doctor. I utilize the principles and practices of natural healing to guide you as a motivator and instructor to assist your body’s own ability to heal and improve your quality of life and health through natural means. I will conduct a thorough case history and decide with you if you should consult the expertise of your medical doctor or naturopath to monitor you during your cleansing program.  PLEASE TYPE YOUR FIRST & LAST NAME AS AN ELECTRONIC SIGNATURE. *
STATEMENT OF ACKNOWLEDGEMENT: I, as a client of BellaBody health coach, Lynesa Williams, have read the above informed consent and understand that this form of natural care is based on historical and current understandings of cleansing principles and practices. I also recognize that even the gentlest of cleansing programs potentially have side effects in the form of certain healing crises. The slight health risks of some cleansing programs include but are not limited to: temporary aggravation of pre-existing symptoms, allergic reactions to supplements or herbs, headache pain and healing crises flu-like symptoms. This program is not recommended for young children or those who are pregnant, may be pregnant or are nursing. Those who are on multiple medications and dealing with chronic disease are advised to consult with and be monitored by their medical doctor or naturopath. I confirm that the information provided above in the BellaBody Wellness Evaluation form is complete and inclusive of all my health concerns and all medications I am currently taking, including over-the-counter drugs and supplements. I also confirm that I have the ability to accept or reject this coaching program of my own free will. I understand that, as a client, I am responsible for all costs incurred as a result of this coaching program including, but not limited to: the cost of all supplemental materials to assist me during the cleanse, my coach’s time, supplies and appointments missed or cancelled without sufficient notice (8 hours). I am aware that costs for this program are out-of-pocket and  will not be covered under private health insurance. Cancellations and refunds: All of our services and products are non-refundable. If you are unable to make your appointment, you must reschedule within 8 hours of your appointment time. If you have to cancel, we do not issue refunds, but we do issue credit towards any of our services or products. PLEASE TYPE YOUR FIRST & LAST NAME AS AN ELECTRONIC SIGNATURE. *
Thank you for completing your Wellness Assessment form.  I look forward to working with you.
This information is for educational purposes only. Not intended to diagnose, treat, cure or prevent any medical condition.  Consult your doctor before starting if you have, or have had, any health condition or if you are taking any medications or remedies including OTC medications, or are planning any medical procedure.
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