Language
English (US)
Health Goals Questionnaire
Please fill this so that I can better assess your needs and build a plan for you accordingly.
Please answer the following so we can start your profile:
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Please share the best email address where I can send your customized plan for you.
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[email protected]
Please answer the following:
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What is your main reason for looking into a healthy living program?
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Need support with my weight management goals
Improve health
Build muscle
Healthier lifestyle
Want more energy
Want to sleep better at night
Want to look and feel more lean and fit
Want to cleanup my gut
Health concerns (please specify below if you can)
Other (Please Specify)
What are some of the obstacles in your daily life right now that currently prevent you from being your ideal healthy self?
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No obstacles, I am ready to begin.
Lack of self control
Limited time to cook healthy meals
Too socially active
Sweet tooth
Shift work or difficult schedule
Do not stay committed to anything for long
I only enjoy delicious flavorful food
Other (Please Specify)
Which other programs or routines have you tried in the past to try to get healthier?
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Keto Diet
Soup Diet/Juicing/Limited calories
Dr. Bernstein
Dr. Poon's
Weight Watchers
Gym/Exercise/Personal Trainer
Just trying to eat clean on my own
Just trying my own workouts on my own
I have never tried anything before
Other (Please Specify)
What would you ideally like to see happen? (Check all that apply)
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Lose weight on the scale
Lose inches around the body so clothes fit better
Maintain my current weight and size, but get my body stronger/healthier
Gain weight/inches to be at a healthy size/weight
Other (Please Specify)
How actively do you currently exercise?
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None
1 to 2 days a week
3 to 4 days a week
5 to 7 days a week
Do you currently take any nutritional products to help support your system and health? For example, like protein, fibre, collagen support, digestion support etc
No
Yes (please share which ones)
Are there any health issues or concerns in particular that you would like to share with us? If you have a diagnosis, or taking medication, it is important that you share this information so that we can respond accordingly.
If I could show you how to achieve your goals without giving up delicious food and still feeling fulfilled each day, would you be ready to begin?
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Yes! This is what I have been looking for!
I am not sure, I would need more information first about the program and how it works.
Where did you come across this Questionnaire?
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Instagram
Facebook
On a Website
Google
Personally Sent Link by Sheela
Other (Please Specify)
When is a good time to get in touch with you? (check all that apply)
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Morning (9am to 11:30am)
Afternoon (12pm to 4:30pm)
Evening (5pm to 8:30pm)
Late Night (9pm to 11:30pm)
Submit
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