Empower Health
Welcome to the first step to see if joining the Empower Health program is right for you! Please provide as much detail as possible so I can serve you effectively during our online session. ~Kate C.
What Is Your Full Name? *
What is your Primary Goal? *
Just the TOP issue, highest priority to you
What are your Secondary Goals *
Select all that apply
Required
Which of the following do you experience at least on a monthly basis? *
Required
Which of the above ones are most severe and/or most frequent? (several times a week) *
What Medications Are You Currently Taking? (Prescription and OTC) *
What, if any, diagnoses or health issue do you have? *
On A Scale Of 1-10 (10 being the highest), How Committed Are You About Achieving Your Goals NOW? *
Low
High
Why have you decided to apply for a Strategy Session today? *
What Is Your Current Nutrition And Exercise Routine? *
E.g. Weight Watchers, FODMAPS, AIP, 5:2, P90X, PT... 20 Minute home workout Monday, Wednesday, Thursday with a 1 hour run on the weekend. Nutrition: Breakfast = 2 x eggs, Lunch = Sandwich with ham and cheese + crisps, Snack = chocolate bar, Dinner = Pasta with bacon and cheese, Pre-bed snack = rice cakes
Have You Heard Of Food Sensitivities, And Understand Their Role In Health And Inflammation? *
What Are Your Health And Fitness Goals Over The Next 90 Days (Include current body weight and goal body weight; any symptoms that are bothering you that you would like resolved)? *
HONESTLY, Why Haven't You Reached These Goals Already? *
What Else Have You Tried To Do To Solve This Already? *
Are You Prepared To Invest Financially To Get The Results You Deserve With The Right Guidance And Support From An Expert In The Field? *
What Is Your Email Address? *
What Is Your Best Contact Number (Including International Dial Code) *
What's The Best Time To Contact You In The Next 24 Hours? *
Required
What is your time zone? *
Anything else you would like me to know before we talk? *
Congratulations! You have successfully submitted your application. I will be in contact with you soon, on your preferred contact number. Please answer any unknown caller IDs in this time. I look forward to chatting!! ~Kate
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