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Health Survey
Health Questionnaire
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Email *
My transformation.  3 years maintaining my goal weight.
First and Last Name (Include your social media name too please) *
Gender *
Age *
Height & Weight *
Email *
Contact # *
If you couldn't fail....How much weight are you trying to lose? *
What other methods have you tried losing with in the past? List them *
What kind of things do you struggle with in your health? *
Besides wanting to look and feel better, please list other main motivations or goals for wanting to lose this weight. *
Do you have any food allergies or dietary restrictions? *
How many cups or oz. of plain water do you drink a day? *
Do you drink any of the following? *
What does a normal day of eating look like for you?  (Breakfast, Lunch, Dinner, Snack) Please include if you pick up/takeout, etc *
How did you hear about this? *
How much do you think you spend on everything you consume daily? *
Do you exercise? If so, what kind of exercise and how often? *
What kind of things do you struggle with in your health?
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On a scale of 1-10, where is your stress on a normal day? 1 being no stress, 10 being very stressed *
If you work, what do you do and does that add to your stress? *
On a scale of 1-10, where is your energy level? 1 being very tired, 10 being lots of energy *
On a scale of 1-10, how ready are you to lose weight, feel better, and learn the habits to keep the weight off? 1 being not ready at all, 10 being I must do this!
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