MW - Evaluation Form
Please fill out with all required information.
To begin the plan, you must fill out the form, choose your plan and send the e-mail with the corresponding photos and measurements (instructions below).
Email address *
Name: *
Friend's Name: *
Friend's E-mail: *
Age: *
Phone: *
Birthdate: *
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Actual Weight (LBS): *
Height (CMS): *
Are you pregnant? *
Are you nursing? *
Do you have any food allergies/intolerances? *
Do you have any lesions or difficulty exercising? *
If the answer to the previous question is yes, how does this affect your daily life?
Do you suffer from any illness? *
If the answer to the previous question is yes, please elaborate.
Do you suffer from a hormonal imbalance? *
If the answer to the previous question is yes, please elaborate. (PCOS, Hashimotos, Thyroid, etc.)
Are you on any medication? *
If the answer to the previous question is yes, please elaborate.
Are you on a specific diet? *
If the answer to the previous question is yes, please choose below or explain.
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How would you describe your digestive system? *
In general, how many hours do you sleep at night? *
What is your activity level? *
How long does your exercise last? *
What type of exercise do you do? *
What is your goal? Choose all that apply. *
Required
On a scale of 1-10, 10 being the greatest, how READY are you to make a change in your life? *
On a scale of 1-10, 10 being the greatest, how WILLING are you to make a change in your life? *
On a scale of 1-10, 10 being the greatest, what is your daily stress level? *
On a scale of 1-10, 10 being the greatest, how woud you say your eating habits are? *
CHOOSE YOUR PAYMENT METHOD - Please note that in order for your plan to activate you must send payment and confirmation.
Clear selection
CHOOSE YOUR PLAN *
PROMO CODE: Enter promo code below *
DISCLAIMER:
Please acknowledge your responsibility to work directly with a medical professional before, during and after seeking a nutrition consult. Any information here provided must not be followed without the authorization of your medical doctor. If you decide to utilize this information without said authorization, you are accepting full responsibility for your decisions.
Join with a friend offer is valid from Monday Jan. 13th - 19th, 2020. Both subscribers must sign up for the same program: Nutrition Only or Nutrition and Workouts. Both subscribers must sign up for a three month program and commitment minimum.
ACCEPTANCE SIGNATURE: Signing this documents binds you to an agreement of a minimum purchase of three months in the program chosen above. *
DATE: *
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THANK YOU!!! I'm so excited to get started! Please use this space to write YOUR expectations from this program. What do you wish it would do for you?
A copy of your responses will be emailed to the address you provided.
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