Language
English (US)
Health Assessment:
Fill this out so we can make sure to set you up for success tailored to YOUR needs.
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
What country do you live in?
Are you a coach or currently working with a coach?
If you knew failure wasn't an option, where would you like to be in 3 months? Think physically, mentally, emotionally, life goals, etc.
Are you willing to invest in a fitness & nutrition program so I can coach you towards achieving your goals? *
What are your health & fitness struggles currently? (I want to know about your digestive health, energy level, weight loss/gain goals, hormonal imbalance, pain, inflammation, etc.) *
On a scale of 1- 10 (1- being cannot get up in the AM and 10 being thriving energy all day) rate your energy level:
Rate your digestive health 1 (poor) to 10 (excellent):
Please rate your level of confidence and ability to be successful:(1 - I don't believe I'll ever be successful. 10 - I know I'll be successful, I have zero doubt.)
What are your biggest barriers to reaching your goals, why have you not been successful in the past? *
Give me a glimpse into your nutrition in a day! What do you eat, when and how much. Are you a stress eater? Chronic dieter? Do you feel guilty when you splurge? How is your self control?
Which nutrition approach do you feel like you'd benefit from more? *
A program with more structure. You'd be told exactly how many portions of each food group to eat every day based on your goals and starting point.
A program with more flexibility. With this approach, you could make it work even while traveling or eating at restaurants focusing on balance.
I do not know.
What is your current fitness level? *
Beginner
Intermediate
Advanced
What flavor of my ayurvedic superfood shake interests you most? *
Vanilla
Chocolate
Strawberry
Cafe Latte
Triple Box (mixed): Chocolate, Vanilla, Strawberry
Barista Box (mixed): Chocolate, Vanilla, Cafe Latte
Would you be interested in doing a 3-Day Cleanse to jump start your metabolism and help banish belly bloat? *
Yes
No
Maybe
Are you interested in a plant based pre-workout/energy booster? *
Yes! Lemon
Yes! Fruit Punch
Yes! Mixed Berry!
No
Maybe
Are you interested in a post workout recovery formula designed to help with results? *
Yes!
No.
Maybe?
Are you interested in a clean-eating plant based Protein snack bars? *
Yes!
No.
Maybe?
Are you interested in joining our team of health coaches and building a business of your own? *This can be as part-time or full-time as you'd like. We have everything set up for you to help you be successful! We know how to make anyone successful whose WILLING to learn! *
Yes!
Maybe!
No.
Submit
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm