Are we a good match? Please tell me about you and let's see: First and foremost, what are you hoping to achieve working with me? Weight loss 10lbs or lessWeight loss 10lbs or moreHormone balanceDigestive issuesOther If "Other", please explain: Were you referred to me? YesNo If "Yes", by whom? Do you understand that this will take some time? YesNo What allotment of time are you willing to commit to? 90 days28 days5 days...want to do the 5-day Reset Challenge Has your Doctor made you aware of a new health condition or one you'd like to avoid? Pre DiabeticThyroid is low/highCholesterolBlood pressureCancerOther If "Other", please explain: Has someone in your family or circle of friends had a health scare? YesNo If "Yes", please explain: When is the last time you had a check-up? Enter date: If you can't remember check-up date: Within the last 2 yearsDon't remember Do you have a General Practitioner (GP)? YesNo Are you on ANY medication? YesNo If "Yes", please list: Tell me a little bit more about you: What does a normal work day look like? Office Job...8-10 hours a dayTravel for your jobActiveStay at home sedentaryEntrepreneur active What are your sleep patterns? 7-8+ hours regularlyless than 7suffer from frequent insomnia What does a normal meal look like to you? Fast Food drive thruFrozen single serving mealssnacker/grazer eat small bites all day longMost meals are pasta/rice with some vegetables and proteinFresh vegetables and protein Are you on a low fat or on fat diet? Low fatFat dietNeither Do you drink soda regularly? YesNo If "Yes", how often? Do you prefer sweet or savory flavors? SweetSavoryNeither Mindset: Are you open to eating Paleo or Keto style meals? YesNo Do you know what that means? YesNo Explain your "style" of eating: Typical American Diet - hamburgers and french friesCultural mealsRestaurants mainlyWhatever doesn't have mold on it in the refrigerator?Not a big eater Do you enjoy cooking? YesNo If "Yes", how often do you cook: Are you open to learning to shop and cook? YesNo If not interested in shopping, would you be willing to order a meal delivery service such as Green Chef, etc.? YesNo Do you want to just take some pills and keep doing what you are doing? YesNo If yes, you might not be a match for my services. I am about education and changing your life. Not just adding pills. Do you feel that what you are doing is working? YesNo Are you able to exercise? YesNo Any exercise limits? If Yes, what are your limits? Please explain (surgeries, injuries, etc.): Are you expecting to count calories and fat grams? YesNo I will be teaching you how to tell your own portions, the "two-hand method". Do you need a strict protocol to follow to succeed? YesNo My philosophy is to teach you how and why to make good decisions, it's up to YOU to make them. Are you READY to make some big changes in your life, because you have come to understand what you are doing is NOT working? YesNo If YES, great attitude! That's the MOST important part. When I suggest that you eat something you may not particularly like, will you be willing to try if we deem it necessary for your success? YesNo Why am I asking so many questions before accepting you as a client? Because I want to work with people who are ready to make a shift in the lives and see big changes. I'm here to guide and expose you to my knowledge as I have learned it, experimented with it and have been successful with it. I want to be able to share my protocols with you and you be eager to learn WHAT is going to work for YOU. No ONE program works for everyone. No one program will work for YOU ALL the time. But educating you on what should/might and or does work for you in the space of time you are walking in RIGHT now, is my goal. As your body changes so will needs. You have to be open to that and learn to listen to your body and know the bad cravings or if your body is asking for something. If that makes no sense to you, it will very soon. If YOU are ready to venture forward and LEARN. Then submit this form along with your name and contact information AND let's get busy healing. Your Name (required) Preferred form of contact: Your Email Your Phone Available time of the day for our weekly call/visit: AMWork hoursPM or after 12 noonEvenings I have read the Medical Disclaimer (required) Please leave this field empty.
