Ask Yourself These Important Questions...

  • Who would you be if food was your friend and not your enemy?
  • What if you could choose to design your own health?
  • Why live a life of mediocre health when you can feel vibrant and alive through all your years?

The answer to these questions lies in simple changes. Small healthy lifestyle choices made every day can bring us to that place of feeling and looking our best.

Over the years of working with women, I’ve identified a number of questions that give me the essential information I need to understand your unique situation and provide guidance and recommendations.

Once I receive your completed questionnaire, I will carefully review it to identify those key areas that are thwarting your best efforts to be healthy. Within a few days I will contact you to set up a convenient time for your free 15-minute complimentary consultation. We’ll discuss your top concerns on the phone and come up with easy doable steps to start you on the journey of greater health.

Although not required, it is recommended to share some confidential, personal information, at your discretion, openly and honestly in this initial well-being questionnaire. I will honor and protect your privacy and confidentiality of any personal information shared with me. All information will be kept strictly confidential.

Personal Information

Your Name (required)

Your Email (required)

Phone Number

Age Bracket (required)

What is your current weight? (required)

What is your current height? (required)

Gender

Are you currently pregnant or nursing? (required)

Do you smoke?

Weight History

How long have you had a weight problem?

How much weight do you think you need to lose?

How much time have you allowed yourself to lose this weight?

Eating Habits

Do you eat breakfast every day?

What would a typical Breakfast consist of?

How much water do you drink in a day?

How often do you eat a heavy meal or snack after 8:00 PM?

How many servings of fresh fruit do you eat daily?

How many servings of vegetables do you eat daily?

Sleep Habits

How many hours of sound sleep do you get most nights?

Activity Level

How active is your typical day (excluding any work-out periods)?

How often do you exercise for at least 30 minutes?

Stress Levels

Rate your current level of Stress (1 - Being Very little to No Stress and 5 - Being Your stress affects your ability to concentrate, sleep at night and you are having difficulty coping with it.)

How long have you been at this stress level?

General Health

Do you have any health conditions you are under a doctor's supervision for?

List any supplements, if any, you take including brand names

What are the top 2 or 3 concerns you would like to discuss? (required)

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