Application for Peak Performance Coaching with Master Coach and HCG Protocol Expert Colin F. Watson Survey

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* 1. Address

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Mobile Phone Number

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* 2. Age

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* 3. What is your current weight and height?

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* 4. Current activity level

0-2x per week

3-5x per week

6 or 7x per week

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* 5. Have you ever used HCG for weight loss?

Yes

Several times

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* 6. What are your fitness goals?

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* 7. How often do you travel?

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* 8. Do you have any travel plans in the next 90 days?

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* 9. Do you have any physical injuries or limitations? please list.

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* 10. Are you on HRT? Hormone Replacement Therapy If so, what do you use?

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* 11. Do you have any eating disorders past or present?

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* 12. Are you an emotional eater?

Yes

Not sure? (please specify)

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* 13. Do you have crave sugar or carbs?

Yes

Other (please specify)

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* 14. Have you currently or in the past been an addict? If yes, are you currently sober? How Long?

Yes -Currently Sober

No - Still Active in my disease

I've been sober - 6 months or less

6 months to 1 year

1 year to 5 years

5 + Years

Other (please specify)

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* 15. Do you have any food allergies or restrictions?

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* 16. How many times per day do you eat?

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* 17. What does a typical day of meals look like for you? Be honest...

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* 18. How many hours per night do you sleep?

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* 19. Medical History - any operations, accidents, illnesses, medications?

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* 20. Describe your present home and family environment. Married, single school aged children at home?

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* 21. Do you feel your sexuality is flowing or is blocked in any way, the past, and current, please?

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* 22. What do you think stops you from reaching your ideal weight and size?

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* 23. WHAT’S YOUR WHY? Why do you want to lose weight now?

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* 24. How will your life be different once you reach your desired weight and size?

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* 25. On a scale of 1-10, how committed are you to making the necessary changes to achieve this goal?

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* 26. On a scale of 1-10, how committed are you to reaching this goal in the next (4) four months?

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* 27. Please list IN ORDER of priority what area (s) you need support in most?

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* 28. Why are you looking to join HCG Quantum Leap now?

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* 29. IMAGINE... If you were able to achieve and maintain your ultimate desired weight and develop an ironclad mindset for long-term success, would you be willing to invest in a coaching program to achieve these goals?

Yes

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* 30. I agree to complete the personality assessment on the thank you page so that Master Coach Colin can learn how to best assist me during our session together.

Yes

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* 31. I understand that HCG QUANTUM LEAP, LIFE COACHING & ENERGY HEALING is not a medical treatment. I also appreciate that it is my responsibility to seek medical care for any problem of illness. *

I understand