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and simplifying your life
Fill out your FREE assessment below
Client Free Assessment
Name
*
First
Last
Email
*
Phone
*
What are your current Health and Wellness goals?
*
check all that apply to you
*
I'd like to lose weight
I'd like to increase my metabolism
I'd like to improve my energy
I'd like to eliminate blotaing
I'd like to reduce my body fat
I suffer from Autoimmune disease
I have Thyroid issues
I have digestion issues
I have chronic inflammation and pain
I'd like to lower my risk and frequency of illnesses
I feel I have an emotional connection with food
I'd like to improve my labs (cholesterol, liver enzymes, blood sugar)
I am diabetic
I'm sick and tired of being sick and tired
I want to feel like myself again
I have difficulty with sleep
What would you say you struggle with most: Check all that apply
*
Weight loss
Yo-Yo dieting
Meal Planning
Self-Love
Working Out
Stress
Do you have weight to lose?
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No, I'm good
> 10 pounds
10-25 pounds
25-50 pounds
50 Plus pounds
How would you describe your energy level?
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I'm a ball of energy
I'm ok, I could use a bit more though
I can't make it through the day without caffeine and/or a nap
How would you describe your stress level?
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I'm calm as a cucumber
I stress every now and then over things
I have stress about my stress
How would you describe your digestion?
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I can eat anything without any issues
I find myself bloated when I eat certain foods
I completely have to avoid certain foods to make my stomach happy
Let's talk sleep. Do you have a hard time staying asleep once you fall asleep?
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Never
Sometimes
Always, I can't remember the last time I slept well.
I feel run down by mid-afternoon.
*
Never, I'm like the energizer bunny
Sometimes
Always, I need me some caffeine to survive.
I am often sick with a cold or the flu
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I don't remember the last time I was sick
I get sick occasionally, less than 2 times per year
I am often sick and require antibiotics to clear things up
I tend to gain most of my weight in my mid-section
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Always
Sometimes
Never
I have often have heartburn
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Always
Sometimes
Never
I have general aches and pains
*
Always
Sometimes
Never
I suffer from cramps during my menstrual cycle
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Always
Sometimes
Never
N/A
I suffer from allergies
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Always
Sometimes
Never
I have hormonal issues
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Always
Sometimes
Never
I am easily agitated
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Always, I have a short fuse
Sometimes
Never
I crave sugary foods between meals
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Always
Sometimes
Never
I am sensitive to gluten
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Yes
No
I'm not sure
I have dry skin and/or skin issues
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Always
Sometimes
Never
I have respiratory issues
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Always
Sometimes
Never
My cholesterol is outside the normal range
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Yes
No
Not sure
My joints are often sore or achy
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Always
Sometimes
Never
I suffer from headaches
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Always
Sometimes
Never
Describe your biggest health challenge and any chronic illnesses
*
Have you tried to resolve any of these issues stated above?
*
What have you tried in the past and how has it worked for you?
*
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