Wellness Questionnaire

I provide one on one coaching, meal plans, group accountability, fitness tips, and more to support you with your goals and results! Feel free to share this link with someone you know that wants to get in better shape!

**PLEASE DO NOT FILL OUT THIS QUESTIONAIRE FORM UNTIL YOU ARE READY TO GET STARTED RIGHT AWAY**

First & Last Name *
Your answer
Your Instagram or Facebook Contact *
Your answer
Email *
Your answer
Phone Number *
Your answer
Location (City, State, Country) *
Your answer
Age *
Your answer
Height *
Your answer
Current Weight *
Your answer
What are your Health/Fitness goals and WHY? *
Your answer
How many times a day do you eat? *
How much money do you spend on food per day? *
How much money do you spend on food when you go out? *
Your answer
How would you rate your daily energy? *
Low
High
How many days of exercise do you get in each week? *
How many days of exercise would you LIKE to get in each week? *
What do you enjoy for exercise? *
Your answer
Which of the following interest you? (Select all that apply) *
Required
Are you currently taking any drugs/supplements? *
Are you interested in earning EXTRA part-time income with Nutrition? *
How serious are you about wanting to achieve your goals? *
Not serious about my goal
I really want to reach my goal
How much are you able to invest in your health program? *
If not TODAY, provide the date you will be able to start below. *
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