* 1. Address: City: State: Zip: Country:

* 2. Best Time To Call

* 3. How did you hear about us?

* 4. Birthday (month/day/year)

* 5. Occupation:

* 6. Marital Status:

* 7. Blood Type:

* 8. Height:

* 9. Current Weight:

* 10. Healthy Goal Weight:

* 11. Please Check Current Health Issues and/or Physical Conditions:

* 12. Please list physical and/or mental health concerns not mentioned above.

* 13. Please list medications you're currently taking and why?

* 14. Allergies & Sensitivities:

* 15. Please select one answer from each row.

  Lots Some Little None
Daily water intake?
Organic food?
Fresh fruit?
Raw veggies?
Fried food?
Canned & boxed food?
Refined sugar/sweets?
Cigarette smoking?

* 16. Please select one answer from each row.

  Daily Weekly Rarely Never
Home cooked meals?
Fast food?
Alcohol intake?
Prayer?
Read the bible?
Meditate?
Time with nature?
Baths?
Exercise?

* 17. Please select one answer from each row.

  Weekly Monthly inconsistently Rarely Never
Attend church?
Are you a tither?
Do you "sow" financially?

* 18. Please select one answer from each row.

  Weekly Monthly Yearly Never
Fasting
Enemas

* 19. Daily bowel movement?

* 20. Please select one anwser for each row.

  4x Yearly 2x Yearly Once Yearly Once or Twice Ever Never
Detoxing
Colonics

* 21. Please select one answer from each row.

  Yes No I Don't Kow
Holding any unforgiveness?
Haunted by some emotional trauma?
Do you know your purpose (calling)?
Are you living your life's purpose (calling)?

* 22. Please select one answer for each question.

  Lots Some little None
Are you experiencing true happiness?
How many people do you feel are holding you back?

* 23. Please select one answer from each row.

  Yes No Maybe
Are you interested in transforming your life?
If you're on medication do you have a strong desire to get off of them?
Are you interested in support?
Are you interested in learning how to eat healthier?
Do you have family or friends that would be interested in Sharing The Bliss?
Would you be interested in becoming a Ceritified Sharing The Bliss Coach?
Are you involved in a church or faith-based group or organization?

* 24. Please list 3 specific URGENT NEEDS you would like to see manifest in your life within the next 12 to 24 months.

* 25. What do you think you need to do to obtain these urgent needs?

* 26. Are you willing to do what ever you have to do to become that person?

* 27. Do you feel stuck? If so please explain?

* 28. Please tell me how you would like a coach to support you?

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You did it! Completing the Sharing The Bliss Health & Wellness Assessment Form has already begun to cause things to stir in the spirit realm... Can't you feel it? Your next step is to schedule your complimentary Transformation Activation Call with me right away by calling 718 273-9772. My half hour Private Breakthrough Calls are normally $175 and my full hour calls are $250, so this is really an awesome opportunity! I'm so excited about going through your form and learning about you. Can't wait to speak with you! I promise, our time together is going to set the path to your Purpose-Driven Dream Life!

Blissful Blessings,
Coach Carmen

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