Free Wellness

PERSONAL DETAILS

 
 
PLEASE ANSWER THE FOLLOWING QUESTIONS AS ACCURATELY AS POSSIBLE

1. Do you work? YesNo
 
2. Do you go to School? YesNo
 
3. Do you take medication? YesNo
 
If yes, please list
 
4. Do you smoke? YesNo
 
5. Do you suffer from any illness/allergies? YesNo
If yes, please list.
 
6. Do you have joint pain? YesNo
 
7. Do you exercise?* YesNo
If yes, please list.
 
8. How is your mood?
CalmSwingsAngry
 
9. What is your energy level?
Not Very ActiveLightly ActiveActiveVery Active
 
10. Do you suffer from anxiety, depression or stress? YesNo
 
11. Do you take vitamins or supplements? YesNo
If yes, please list.

EATING PATTERNS
Breakfast
 
Lunch
 
Dinner
 
12. How many beverages/alcohol do you have per week?*
 
13. Do you have a family history of diabetes, Strokes, heart disease, cholesterol, high blood pressure, other?
 
14. Do you eat out?* YesNo
 
15. If yes, total cost spent per week eating out:
 
16. How is your digestion?* NormalGas/BloatingHeartburnSluggishCrohn'sCeliac
 
17. How is your elimination?* Normal (no issues)ConstipationIBSIBDColitis
 
18. On a scale of 0-10, how committed are you to achieving this goal by this date?*
 
19. What are your goals?* Weight LossWeight GainEnergySleepImprove DigestionOther
 

"YOU ARE THE AVERAGE OF THE 5 PEOPLE YOU SPEND THE MOST TIME WITH"

 
20. Please list below 7 of the people your closest to or spend the most time with (list as many as you can)*
 

Once you complete the list, we believe to significantly increase your chances of reaching your health goal, can you commit to by the end of today message each of those people to inform them of your goal and the date you set to achieve this goal by? (please text your coach once you have successfully made this declaration to all those people)

 
Tick here if your ready to do this and will promise to report back to your coach once it done within 24-48 hours*
 
YOUR GOAL:*
 
DESIRED RESULT:*
 
DATE MUST ACHIEVE THIS BY:*
 
Your PRIVACY is important to us. Rest assured that your private information will be kept confidential, and will not be shared nor will it be used for any other purposes.