First Name *
Last Name *
Email *
Phone *
Birthday *
What is your main health concern? *
How often does it bother you? *
Everyday
Once per week
2 to 3 times per week
Once per month
How long has it been going on? *
1-6 months
1-3 years
Over 3 years
What (or who) would prevent you from completing a program that would rebuild your health from the inside out, recharge your energy and make you feel incredible?
Children
Spouse
Time
Self
Money
Resources
Job
Fear
What have you tried that has or has not worked? *
What is your diet like? Please be specific: meals, foods, diet.. *
How is your energy throughout the day? Low, high, fluctuating? *
Are you taking any supplements or medications? Please list what you take and what it's for. *
What would you like your health to be in 3 months from now? How about 6 months from now? *
What obstacles, challenges, and struggles do you face regarding diet/lifestyle? *
If we were to work together what would you expect to achieve from working with me? *
What are 5 things you LOVE about your life? *
Yes! I want to get awesome health tips, tools and resources!
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