YOUR AGE:
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CURRENT WEIGHT:
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On a scale of 1-5, how would you rate your daily energy level, on average?
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1 - Tired/low energy all or most of the day.
2 - Tired/low energy about half the time.
3 - Good energy, except after meals when my energy slumps
4 - Good, steady energy all day
5 - High energy all day long!
How many steps do you get, per day (on average)?
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More than 10,000
6,000-10,000
Less than 6,000
In addition to walking, how often do you get other kinds of exercise, on average?
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6 or more times per week
3-5 times per week
1-2 times per week
Rarely or never
Does your exercise usually include high-intensity cardio (significantly elevated heart rate for MORE THAN 10 minutes at a time)?
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Yes
Sometimes, but not usually
No
Do you weight train 2 OR MORE times per week, using HEAVIER than 5-lb weights?
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Yes
No
How would you rate your gut health?
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Poor (often have problems with bloat, digestion, inflammation and/or intestinal issues, etc)
Medium (sometimes have problems with bloat, digestion, inflammation and/or intestinal issues, etc)
Great, no gut issues.
Approximately how many calories do you consume in a typical day?
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Less than 1,300
1,301-1,700
1,701-2,100
More than 2,100
It’s very inconsistent day to day or weekday vs weekend
I have absolutely no idea
Approximately how many grams of protein do you eat each day?
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Less than 60
60-110
More than 110
I have no idea
How is your quality and quantity of sleep most nights?
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less than 7 hours of sleep most nights
It often takes me a long time to fall asleep OR I wake up in the night and have trouble getting back to sleep
7-9 hours of uninterrupted sleep & I wake up feeling fully rested
More than 9 hours of sleep
How stressful is your average day (these past few months)?
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Extremely stressful - sometimes off the charts
Fairly stressful - I’m pretty stressed most days
Sometimes stressful - depends on the day or situation
Once in awhile, but not often
Never or very rarely stressful
What do you MOST want, regarding your health? (Choose your TOP 2)
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To lose weight/fat
To have more energy
To improve heart, gut, bone and brain health
To be more fit, toned and strong
To lower my biological age
What is your biggest challenge in achieving those health goals?
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Are you open to professional guidance such as nutritionists, personal trainers, or medical weight loss programs?
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Yes
No
What type of weight loss support are you most interested in? (check all that apply)
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Personalized, private one-to-one coaching
Group coaching where I’m part of a community
Meal planning & nutrition guidance
Fitness training & workout programs
Medical weight loss options (GLP-1's, peptides, etc)
Where should I send your results?
Last Name
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First Name
Email
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Phone
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