First Name
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Last Name
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Age
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What is your current weight?
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What is your goal weight?
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Do you feel it's more challenging to lose or maintain weight as you age?
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Yes
No
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How would you rate your ability to handle stress?
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I handle my stress amazingly well
I could be better at handling my stress
I don't handle stress well at all
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What have you tried in the past to lose weight? (Choose All That Apply)
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Ozempic, Wegovy, or other medications
Optavia
Dr. Monitored Weight Loss
GOLO
Low Calorie Diets
Intermittent Fasting
Keto
Vegan
Low Carb Diet
Low Fat Diet
Raw Food Diet
Cabbage Soup Diet
Atkins Diet
Fat Burner Pills or Supplements
Cardio
Jenny Craig
Weight Watchers
Eat Clean / Watch What I Eat / Other
I've never tried to lose weight
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Do you have a sedentary job that may be playing a role in slowing down your metabolism?
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Yes
No
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How many steps do you average per day
I do not track my steps
0-5,000 steps
5,000-10,000 steps
10,000+ steps
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How much protein do you eat on average each day?
I do not track my protein every day
0-50 grams of protein
50-75 grams of protein
75-100 grams of protein
100-125 grams of protein
125+ grams of protein
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How much water do you drink on average each day
I do not track my water intake
0-32 ounces of water
32-64 ounces of water
more than 64 ounces of water each day
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How much sleep do you average per night?
I do not track my sleep
Average less than 7 hours per night
Average between 7 and 9 hours per night
Average more than 9 hours per night
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Would you be interested in our 1:1 coaching program.
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