Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Your Location (City, State)
City / State
Your Age
Age
Preferred Method of Contact
*
Call
Email
Text
Medical
We can discuss your medical considerations when we chat.
Sleep
What time do you normally go to bed?
What time do you usually wake up?
Do you sleep well?
Yes
No
Sometimes
Hydration
How many ounces (or cups) of "plain" water do you drink in an average day?
What non-water beverages do you consume in an average week:
Coffee
Soda
Sports or Energy Drinks
Tea
Juice
Alcohol
Other
How much alcohol do you drink in a week?
Movement
How many times per week do you exercise?
What kind of exercise do you participate in?
How would you rate your daily energy level?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Stress
What is your occupation?
Rate your overall stress level
Low Stress
1
2
3
4
5
6
7
8
9
High Stress
10
1 is Low Stress, 10 is High Stress
What are the stressors in your life?
Eating Habits
What time do you eat your first meal?
How many meals per day do you eat?
Do you snack? What do you snack on?
How often do you eat out in a week?
Weight / BMI
Have you tried to lose weight before? If so, what program/method did you use?
What is your primary health goal?
Weight Loss
Feel Better
Learn Healthy Habits
Other
If Weight is your goal, how much weight would you like to lose?
What is your height? (Feet/Inches)
Based on your height a current weight, what is your BMI value today?
What is your personal goal / target BMI value?
On a scale of 1 to 10, how ready are you to make changes to improve your health?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Submit
Thank you! We will be in touch with you shortly. You can also email me at julie4sara@gmail.com
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