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General Wellness Inquiry

check our our General Wellness Assessment to dial in the areas for you to make immediate improvements, never underestimate breaking down the basics!!!

Basic Heart Health Assessment

Lock in on Heart Health and don't wait for the warning signs, be proactive about educating yourself and taking action now!!

Weight Loss Specific Survey Form

Are you wanting to make a major shift in Health by dropping some weight? Struggled before but now you are wanting to make it happen, find the solution, and see the RESULTS!! Our specific weightless protocol is for you, let's talk, fill out the form and we will get back to you with a plan of action right away!!

Full Name

Email *

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

How did you hear about our services?

Internet Search
Social Media
Referral
Other
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Which weight loss services are you interested in?

Meal Plans

Exercise Programs

Supplements

Coaching Services

Other

What are your primary reasons for wanting to lose weight?

Health improvement

Increase energy levels

Enhance self-confidence

Improve mobility

Other

Other (Please specify):

How would you rate your current level of physical activity?

Sedentary (little to no physical activity)
Light (minimal activity, such as walking)
Moderate (regular exercise, such as jogging or cycling)
Vigorous (intense workouts or sports activities)
Unsure
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Are there any specific dietary restrictions or preferences we should consider in your weight loss plan? (check all that apply)

Vegetarian

Vegan

Gluten-free

Dairy-free

Other

If other please specify:

What are your long-term health goals beyond weight loss? (check all that apply)

Improve overall fitness

Reduce risk of chronic diseases

Achieve better mental well-being

Increase longevity and quality of life

Other

List any other long-term health goals: