Small Hinges Deep Dive Intake
Take this survey to find out what small hinges are best for you to try.
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NEW PARTICIPANTS: I'll need your name, address, email & phone #, PLUS, an honest account of your goals, what motivates you, what you are willing and ready to change, and any medical conditions, medications and allergies you might have. Let's get started...
1. CONTACT INFO 
NAME:  *
Company *
Address: *
Zip -
 *
Country - *
Email -  *
Cell number -  *
2. Health & Wellness 
Birthdate:  *
MM
/
DD
/
YYYY
Height: *
Weight:  *
BMI *
Health Conditions *
MTHFR or Genetic Mutations *
Medications (including Supplements):  *
Have you taken an igG food sensitivity test? (KBMO FIT, Pinnertest, Everlywell, etc.)  *
Allergies and igG food sensitivities? *
Blood type *
Injuries and surgeries (date)  *
Major life changes (date) *
Family structure (married? children? divorced?)  *
Mental health concerns / issues unknown *
How much sleep per night? On average. *
Alcohol or drug use, what and how often? *
Programs / diets tried previously (please add results) *
Exercise (what and how often)  *
Hobbies (what and how often) *
Obligations to others (kids, work, volunteer) *
Fitness/health tracker (Whoop, FitBit, etc.?)
 *
How often do you have a bowel movement? 
 *
Do you drink coffee, if so how much? 
 *
How much water do you drink per day? 
 *
3. Weekday schedule (wake, eat, work, exercise, sleep) 
Wake up
Time
:
Breakfast
Time
:
Snack 
Time
:
Lunch 
Time
:
Dinner
Time
:
Desert
Time
:
Exercise 
Time
:
Get in bed
Time
:
Fall asleep
Time
:
Sleep interruptions
Time
:
4. WeekEND schedule (wake, eat, work, exercise, sleep)
Wake up
Time
:
Breakfast
Time
:
Snack
Time
:
Lunch
Time
:
Dinner
Time
:
Desert
Time
:
Exercise 
Time
:
Get in bed
Time
:
Fall asleep
Time
:
Sleep interruptions
Time
:
5. Goals of Small Hinges Changes
100% yes
Would be a nice added benefit
Not sure I can have that
Need more info
Not applicable
Weight loss
Reduce pain
Heal disease
More energy
Balance hormones
Boost immunity
Mental clarity
Diabetes control
Happier / Less Stress
Hair / Skin / Nails
Confidence
Better Relationships
Financial security
Fertility
Knowledge of what works for me
6. Deep Dive into Goals & Planning (answer "NA" for anything that is Not Applicable to you)
What do you feel you NEED to change? 
What do you feel you CANNOT change?
What do you feel you CAN change easily?
What results are you looking to achieve by working with Small Hinges? 
What results are you looking to MAINTAIN long term? 
How quickly do you NEED to see results?
How quickly do you WANT to start? 
What is blocking you from starting? 
What is your current feeling about starting? (scared, confused, excited, ready, lazy, frustrated, unsure, etc.) 
Do you like to cook? 
Do you live with someone who likes to cook?
Do you like to exercise? If yes, what type of exercise do you enjoy?
Do you have a dog?
Do you live in a house, apartment, or townhouse/multi-family? 
What do you do for work? 
Do you feel financially strapped/stressed?
Does your financial situation impact the type of food, beverages, supplements you consume? Does it impact the type of exercise you do, skincare you use, mode of transportation, area you live? (be specific)
Do you commute to work? Or work from home? 
If you have children, how old are they? (put "N/A" if you do not have children) 
Do you feel you can be fully self-expressed in your relationships? 
Do you feel you have love and support from your family and friends? 
Do you feel you have support from your colleagues and superiors? 
Do you feel that you NEED 1-on-1 support from a coach?
Clear selection
How much time do you spend watching TV and on your devices PER DAY? 
Write a statement that represents how you feel about yourself RIGHT NOW?
7. Do you consider yourself any or some of these (check ALL that apply):
8. What I LOVE to Eat and Drink? (list EVERYTHING you LOVE)  
Breakfast, lunch, dinner, snacks, desserts, beverages...

9. What I CANNOT Eat & Drink... (list EVERYTHING, and why - don't enjoy vs. allergy vs. aversion vs. bad reaction)
Breakfast, lunch, dinner, snacks, desserts, beverages...
10. Which Small Hinge Changes Would You LIKE to Try?
Ready right now
Will try next/soon
Need more info
Maybe
Never
Diet
Beverages
Exercise
Sleep
Mindset
Environment
Schedule
Relationships
Extra Curricular / Hobbies
Financial
Job / Career
Volunteer
11. Would you like additional coaching?
Clear selection
12. By filling out this form, I agree to participate in a program or consultation with one of Small Hinges LLC’s team of experts. I understand that Small Hinges LLC is not a medical institution, and will follow any received advice, recipes or guidance with my health, allergies, medication, injuries, and wellbeing in mind. I will not hold Small Hinges LLC or any participating "experts" or employees of the company liable for any recipes shared, advice or supplements recommended, that negatively impact or hurt me and/or my family. No refunds, discount no exchanges shall be given for any reason. All of the information I've shared in this survey is true and current to the best of my knowledge. I agree to share my data to experts, research organizations, and other partners of Small Hinges LLC. I promise not to copy, share or give access to Small Hinges' documents, programs, meal plans, lifestyle changes, supplements, workshops, events, etc. I am solely responsible for the result of implementing the protocol from any programs, consultations, workshops, etc., and any ongoing plans from Small Hinges LLC in my own life. Small Hinges LLC does not make any representations, promises or guaranteed outcomes from their app, programs, challenges, consultation, and will not be held liable for any reason. *
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