Name
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First Name
Last Name
Email Address
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Phone
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Age
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Gender
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Height
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What is your current weight?
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On average, how many hours of sleep do you get per night?
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Do you consume alcohol? Approximately how much/how many times per week?
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Approximately how many hours of television do you watch per week?
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Do you cook at home?
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How many times a week do you eat out? Include a few of your favorite restaurants.
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Do you consume fast food (include restaurants/typical food)?
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Do you have any food allergies or intolerances?
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Do you currently exercise? If so, what types of activities do you enjoy? How frequently are you getting physical activity?
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Are you currently being seen by a medical professional for thyroid, hormone imbalance, stress, anxiety, or any other medical condition that could impact weight? If yes, are you treated with medication for the condition(s)? Please list.
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Have you ever suspected you currently have or have had an eating disorder? If yes, please briefly explain.
On a scale of 1-10, what is your current stress level?
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What day-to-day challenges do you face that impact your ability to take the best care of yourself?
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If you could pick one “culprit” or habit that is sabotaging your health, what would that be?
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List two to three positive things you do for yourself on a regular basis?
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What area in your life are you seeking a breakthrough?
On a scale of 1-10, 10 being completely ready, how willing are you to make changes that will help you achieve your health goals?
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How did you hear about us?
