Final Step: Please Complete This Quick Form To Reserve
Your Free Health Strategy Session

Please fill out the form below so we can prepare for your appointment. If we don’t receive it, your appointment will be canceled.

First Name*



Last Name*



Email*



Phone Number*



Age



Height



Current Weight



Would you like your weight to be different?



If so, what?



Where do you currently live?



Relationship Status



Children



Pets



Occupation



Annual Income




Under $100k



$100 – $250k



$250k – $500k



Over $500k


Hours of work per week



Please list your main health concerns



Other concerns and/or goals?



At what point in your life did you feel your best?



Any serious illnesses/hospitalizations/injuries?



How is your sleep?



How many hours?



Do you wake up at night?



Why?



Any pain stiffness or swelling?



How many bowel movements do you have per day?



Constipation/Diarrhea/Gas?



Allergies or sensitivities? Explain please



Do you take any supplements or medications? List please:



Any healers, helpers, or therapies with which you are involved? List please:



What role do sports and exercise play in your life?



What foods did you eat as a child? Breakfast/ Lunch/ Dinner/ Snacks/ Liquids



What is your food like these days? Breakfast/ Lunch/ Dinner/ Snacks/ Liquids



Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?



Do you crave sugar, coffee, cigarettes, or have any major addictions?



The most important thing I should do to improve my health is…



On a scale of 1-10 how serious are you about changing your health & your life?



Anything else you would like to share?



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