Healthy Change Campaign
Takes about 10 minutes to complete.

Please complete the following survey and send back by hitting the "Submit" button once done. It will automatically go to my email address of tmackisagenix@gmail.com

I am so excited to assist you in your health and wellness goals for both the short term and the sustainable long term.

Your responses will assist me in helping to guide you on how to get started for you to achieve the most success in reaching your goals while taking into consideration your current lifestyle, schedule, and healthy change priorities. Thank you for taking the time to complete this "Healthy Change Campaign" survey.
Email address *
1. Please Fill in Your First and Last Name *
Your answer
2. What is the best phone number to reach you? Please use (_ _ _) _ _ _- _ _ _ _ format thank you! *
Your answer
3. Is that a cell phone? *
4. Do I have your permission to send you emails and an occasional text messages? *
5. Please prioritize the following by selecting the box that best describes how you feel about each category. (For example, if Increased energy is a big priority for you, select the "Very Important" box for that category) *
Very important
Somewhat important
Not important right now
Weight Management
Increased energy
Improved athletic performance
Healthy aging
6. If you could be on your way to any health goal in the next 30 days, what specifically would it be? *
Your answer
6 b. Why is that important to you right now? *
Your answer
7. If you could be on your way to any health goal in the next 60 days, what specifically would it be? *
Your answer
7 b. How long have you wanted to achieve that goal? *
Your answer
8. If you could be on your way to any health goal in the next 90-120 days, what specifically would it be? *
Your answer
8 b. How serious are you about achieving these goals on a scale of 1-10? ( 10 being the highest) *
Not very serious/I'm not sure I can do it
100% committed *ALL IN!
9. Who else in your life has watched you work towards achieving this goal? (e.g family member, spouse, children, co-workers, friends, workout partners)
Your answer
10. What programs or methods to achieve these goals have you tried in the past? (Examples could be eating organically, elimination diets, weight watchers or other programs.) *
Your answer
10b. On average, how much money per month have you spent to achieve your goals? *
Your answer
11. Describe how is it going to feel when you achieve that goal? What are some things you will do that you may not be doing now? *
Your answer
12. Do you eat 3 meals a day, skip meals, grab breakfast or lunch on the go? (Check all that apply) *
Required
13. How often do you eat out? *
Your answer
14a . Do you snack after dinner? *
14b. If yes, what do you typically eat after dinner?
Your answer
15. Do you drink coffee? Energy drinks, soda? Alcoholic beverages? (Check all that apply) *
Required
15 b. Do you currently eat protein shakes or smoothie bowls or protein supplements on the go? *
15 c. Do you take vitamins? *
15 d. How often do you eat processed food or fast food? *
16. How much water do you drink per day? 8 ounce glasses is the standard size *
17. What do you currently do for a living and What do you love about what you do? *
Your answer
18. If you had more time- what would you do with it? *
Your answer
19. What is your favorite snack or meal? *
Your answer
20. What is your favorite activity? *
Your answer
21. Are you aware that this program comes with 2 great tools!?! One that assists in identifying habits and keeping the ones that serve our goals and replacing the habits that don't? AND the other one that is an accountability program which allows everyone who completes it to earn a $200 product coupon every 16 weeks? (Up to 3 times per year!) *
22. As you look ahead at the next couple of months, what do you see as the most effective and streamlined change for you? (Check all that apply) *
Required
23. Which friends and family members are you now thinking of whom you would like to join you? (Even if they are not currently members of LizFit?) *
Your answer
24. What would you like me to know that I did not ask you about? (e.g. medical restrictions, food restrictions, food allergies, injuries, etc.) *
Your answer
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