New Client Application
Please fill in the questionnaire below
Name
*
First Name
Last Name
E-mail
example@example.com
Phone Number
*
Do you feel that you receive balanced nutrition from the foods you eat?
Yes
No
How would you describe your energy levels?
Terrible
1
2
3
4
Kick Ass
5
1 is Terrible, 5 is Kick Ass
Would you like to:
Have More Energy
Improved Self Esteem
Prioritize Yourself
Lose Weight
All of the Above
What's your RESET Budget?
$999-$1999
1999 -2999
2999 +
Other
Do you exercise?
Not at all
1
2
3
4
Regularly
5
1 is Not at all, 5 is Regularly
Do you have any health concerns?
Diabetes
Heart Disease
Stroke
Obesity
None
Other
Anything else you would like to share with Shanna?
Submit
Should be Empty:
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