Client Free Assessment

Name*

First Last

Email*

Phone*

What are your current Health and Wellness goals?*

check all that apply to you*

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?*

No, I'm good
> 10 pounds
10-25 pounds
25-50 pounds
50 Plus pounds

How would you describe your energy level?*

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?*

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?*

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?*

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*

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*

Always
Sometimes
Never

I have often have heartburn*

Always
Sometimes
Never

I have general aches and pains*

Always
Sometimes
Never

I suffer from cramps during my menstrual cycle*

Always
Sometimes
Never
N/A

I suffer from allergies*

Always
Sometimes
Never

I have hormonal issues*

Always
Sometimes
Never

I am easily agitated*

Always, I have a short fuse
Sometimes
Never

I crave sugary foods between meals*

Always
Sometimes
Never

I am sensitive to gluten*

Yes
No
I'm not sure

I have dry skin and/or skin issues*

Always
Sometimes
Never

I have respiratory issues*

Always
Sometimes
Never

My cholesterol is outside the normal range*

Yes
No
Not sure

My joints are often sore or achy*

Always
Sometimes
Never

I suffer from headaches*

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?*

Let’s work on improving your health and wellness

and simplifying your life

Fill out your FREE assessment below

Client Free Assessment