Submitted: Pre-Booking Discovery Call

First Name *
Last Name *

Email *

Phone *

What is your main health complaint(s)? *

How often does it bother you? *

EverydayOnce per week2 to 3 times per weekOnce per month

How long has it been going on? *

1-6 months1-3 yearsOver 3 years

How committed are you to achieving your best health allowing for you to live your best life?

(Scale 1-10, ie:1 being "I have absolutely no motivation" or 10 being "I will do anything to reclaim my health, I'm ALL in!")

1

2

3

4

5

6

7

8

9

10

What (or who) would prevent you from completing a health-rebuilding or weight loss program?

Children

Spouse

Time

Self

Money

Resources

Job

Fear

What have you tried so far that has or has not worked? *

What is your current diet like? Please be specific: list breakfast, lunch, dinner and snacks, as well as the times you eat. *

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 3 things you LOVE about your life? *

Yes! I want to get awesome health tips, tools and resources

Your privacy matters! Your information will be kept private

because that's how it should be :)