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? BOOK YOUR FREE HEALTH STRATEGY SESSION NOW