Mama O'Neill Consult Worksheet - 2017

New Applicant Information

NEW PARTICIPANTS: I'll need your name, address, email & phone # here...

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* 1. Contact Info

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address *

Phone Number *

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* 2. By filling out this form, I agree to participate in a consultation with Lindsay O'Neill, to help me lose weight, and live a stress-less, healthier, and happier life. I understand that Lindsay is not a medical professional, and will follow her advice with my (and my family's) health, allergies, injuries, and wellbeing in mind. I will not hold Lindsay or any participating "experts" liable for any recipes shared, advice or exercises given, that negatively impact or hurt me and/or my family. I am solely responsible for the result of implementing the teachings from this consultation and ongoing plan in my own life.

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* 3. Health & Wellness

Age

Height

Weight

BMI (if known)

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* 4. Dietary Restrictions & Allergies

Allergies

Dietary Restrictions

Medical Conditions

Injuries

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* 5. YOUR favorite foods (list EVERYTHING you love to eat - breakfast, lunch, snack, dinner, dessert, drink)

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* 6. What vitamins & supplements do you take? How much and how often?

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* 7. Exercise - Please tell me about your exercise program (if you have one). Do you walk to work? Run? Play sports? How often? etc.

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* 8. How many alcoholic beverages per week (on average) and what kind of alcohol?

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* 9. What do you want to achieve from working with Lindsay?

Weight loss/diet plan?

More energy?

Happier?

New recipes and tricks for making healthy food taste good?

Overall health & wellness?

Other

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* 10. How did you learn about Lindsay?

Thank you so much for completing this form. I look forward to working with you!

Lindsay (Mama) O'Neill