Filling out the form below will help me understand what your specific goals are in order for me to recommend the best program to fit your lifestyle.

What is your name and how did you hear about me?

Question Title

* 1. What is your name and how did you hear about me?

What is your primary lifestyle goal?

Question Title

* 2. What is your primary lifestyle goal?

What is your secondary goal?

Question Title

* 3. What is your secondary goal?

Why is now the time you want to take steps to reach your goal?

Question Title

* 4. Why is now the time you want to take steps to reach your goal?

What change would you like see in the next 6-12 months?

Question Title

* 5. What change would you like see in the next 6-12 months?

Do you take a multi-vitamin or any other supplements such as vitamin D or vitamin E daily?

Question Title

* 6. Do you take a multi-vitamin or any other supplements such as vitamin D or vitamin E daily?

What do you currently eat for breakfast/lunch/dinner each day? Caffeine? List:

Question Title

* 7. What do you currently eat for breakfast/lunch/dinner each day? Caffeine? List:

How much would you say you spend on food for breakfast and lunch each day? For example, a salad at Panera with a drink is $13 so that’s one meal. Include trips to Donkin Donuts, Starbucks, etc.

Question Title

* 8. How much would you say you spend on food for breakfast and lunch each day? For example, a salad at Panera with a drink is $13 so that’s one meal. Include trips to Donkin Donuts, Starbucks, etc.

How often do you exercise? Are you interested in having a fitness plan created for you?

Question Title

* 9. How often do you exercise? Are you interested in having a fitness plan created for you?

On a scale of 1-100 (100 being the strongest), how serious are you about making your health & wellness a priority?

Question Title

* 10. On a scale of 1-100 (100 being the strongest), how serious are you about making your health & wellness a priority?

1 100
i We adjusted the number you entered based on the slider’s scale.

T