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Personal Information
First name
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Last name
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Telephone
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Email
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Street address
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City
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State/Region
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Postal code
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Current Weight
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Height
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Date of birth
Medical History
Do you have/had any of the following:
Cancer
Cardiovascular Disease or Events
Hormone Replacement Therapy
Depression
Gallbladder Issues
Gastrointestinal Issues
Headaches or Migraines
Hysterectomy
High Cholesterol
High Blood Pressure / Hypertension
Anxiety
Kidney Disease
Organ Transplant / Removal
Pregnant or Nursing
Thyroid Issues
Diabetes
Other
List any medications you're taking:
Known food or drug allergies:
Please select any of the following experiences that may apply to you.
Reflux
Gas/Bloating
Constipation
Diarrhea
Brain Fog
Energy Crashes
Waking Up Multiple Times in the Night
Trouble Winding Down for Sleep
Moodiness
Frequently Sick
Hypoglycemia (Low Blood Sugar)
Snoring
Trouble Falling Asleep or Staying Asleep
What other factors do you feel may be impacting your ability to lose weight or feel your best?
(i.e. such as sleep, stress, work schedule, illness, menopouse, or past life events like divorce/death in family/birth of child):
Do you have any specific dietary requirements (strong dislikes, allergies, vegan, vegetarian, etc.)? If yes, please explain:
Motivation + Lifestyle
What is motivating you to lose weight?
(Are there any personal or external factors that are driving this desire?)
On a scale of 1-10, how would you describe your life stress?
(1-10, low to very high)
How many times per week do you consume alcohol?
On average
On average, how many hours of sleep do you get each night?
Please describe your current activity level.
This can include exercise, lifestyle factors such as an active job, etc.
How is your weight impacting your quality of life?
(ex. energy, sleep, self confidence, love life, ability to move or feel comfortable, motivation)
What have you done to lose weight in the past? What did you find helpful or not helpful about your previous programs or attempts at losing weight?
Do you have a support system at home?
Yes
No
Sometimes
On a scale of 1-10, How open are you to making lasting lifestyle changes?:
(1-10, not at all to very open)
Goals
Goals
Any other lifestyle goals or events coming up you’re motivated to lose weight for?
Which Program Are You Interested In Learning More About?
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Weight Loss & Metabolic Reset Program
Flexible Lifestyle Program
Unsure
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