Do You Qualify? - Premium Coaching

1

Name* This field is required.

First Name

Last Name

2

Email Address:* This field is required.

3

On a scale of 1-10, how bad is your PAIN?:* This field is required.

1 - little / 10 - EXCRUCIATING

4

On a scale of 1-10, how STRESSED OUT are you?:* This field is required.

1 - little / 10 - MAXED

5

On a scale of 1-10, how's your ENERGY?:* This field is required.

1 - low / 10 - great

6

How are pain, stress or low energy AFFECTING YOUR LIFE?* This field is required.{1} Physical Pain, {2} Stress, {3} Low Energy

8

Do you BELIEVE you can FEEL BETTER?* This field is required.

YES, I DO!I'M NOT SURE.

9

Is there anything else you'd like to share?ex. How long has this been going on?