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Health Assessment
The answers to these questions help me to understand your current health "snapshot" and how to best individualize your program and support you in the best way possible.
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Phone
*
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Current Weight
*
Your answer
Height
*
Your answer
What benefits would you like to experience in the next 30-90 days?
*
Detoxification
Less Discomfort
Improved Mobility
Increased Energy
Enhance Mental Clarity
Sleep Better
Sugar Balance
Build Lean Muscle Mass
Stop A Habit
Better Athletic Performance
Improved Digestion
Decrease Stress Level
Improve a Relationship
Weight Loss
Weight Gain
Other:
Required
If Weight Loss Checked Above - How Much Would You Like To Lose? (pounds)
Your answer
If Weight Gain Checked Above - How Much Would You Like To Gain? (pounds)
Your answer
When I gain body fat, I put it on around
*
My middle
My hips & thighs
I am 100% Coachable (open to suggestions to set me up for success and stretching me out of my comfort zone
*
Yes
No
Other:
Required
If Selected No or "Other" please explain % and why
Your answer
I prefer to be contacted by
*
Phone
Email
Text Message
Required
My current level of motivation to accomplish my goals is
*
very low
1
2
3
4
5
6
7
8
9
10
very high
Why is your motivation where it is? How will your life be different if you reach your goals.
*
Your answer
The challenge (s) I see myself having over the next 30 days is / are:
*
Your answer
My current level of stress in my life is:
*
laid back all the time
1
2
3
4
5
6
7
8
9
10
totally stressed out
My main sources of stress are:
*
Your answer
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