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3 Month Wellness Plan Application
Please complete this form to determine qualification so that I can create a simple and customized Wellness Plan for you.
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Name (First Last) *
How would you describe your present state of health? *
Are you taking any medication? If yes, do they interact with foods or weight loss in any way? *
Do you have any conditions I should be aware of? Please list. (ie. allergies, arthritis, celiac disease, Chrohn's, IBS, Chronic Fatigue, etc.) *
Top 3 Health Goals
 in order of priority
1st Health Goal *
2nd Health Goal *
3rd Health Goal *
What health practices are you currently doing for these goals? *
Are you currently following a specialized diet (ie. low sodium, low fat, low carb)? If yes, Please specify. *
What do you consider to be the major issues in your diet and eating plan? *
How much physical activity/movement do you participate in per week? *
Color Personality
Take the Color Personality Test here:
https://jacobadamo.com/personality-colors-quiz/?mc_cid=34718da51e&mc_eid=2cf0a92162
What are your first and secondary Color personality? *
Love Language
Take the Love Language Test here:
http://www.5lovelanguages.com/profile/
What is your first and second Love Language? *
Are you willing to commit to your wellness plan for 3 months to realize results? *
I am READY to take control of my health and I am ALL IN! *
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