Request for Program Info
with Jennifer Wilson, Purposeful Health LLC
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Mobile Phone Number
*
Please enter a valid mobile phone number.
Format: (000) 000-0000.
Time Zone
*
Please Select
Eastern
Central
Mountain
Pacific
Age
*
How did you hear about our programs? (If referred, by whom?)
Please tell us more about your current health & habits
Sharing your current reality will help us select the best plan to fit your needs! This isn't a "diet". This is a program designed to change your foundational habits and mindset--which WILL move you towards your healthy weight. Let's start by understanding where you're starting!
Please describe your WHY to becoming a healthier version of yourself. (What is your main motivation? Relationships, activities, how you feel, clothes fitting, etc)
When was the last time you remember feeling your best in your health or being at your ideal weight or size? (if that is part of your goal)
Sleep
What time do you typically fall asleep at night?
How is your quality of sleep? Do you rise feeling rested?
What time do you typically wake up?
Hydration
How many ounces of water do you typically drink per day?
Do you consume any other beverages?
Coffee
Soda
Tea
Alcohol
Motion
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
Rate your daily energy level
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How would you describe your daily activity level?
Please Select
Low (under 3k steps)
Medium
High (over 10k steps or more than 45 min daily activity/workout)
How many times a week do you exercise?
Please Select
not currently exercising
once a week
twice a week
3 times a week
4 or more times a week
Are there any physical activities that you desire to get back to or start up once you're at a healthier weight? Or anything you currently do that feel better at a healthier weight?
If currently exercising, how many times a week?
How would you describe your daily activity level? LOW (under 3K steps), MEDIUM, or HIGH (over 10K steps or >45 min daily workout)
Stress
an impactor of health
Rate your level of stress or worry
Low Stress or Worry
1
2
3
4
High Stress or Worry
5
1 is Low Stress or Worry, 5 is High Stress or Worry
Rate how much you enjoy what you do for work
Do not love
1
2
3
4
LOVE it!
5
1 is Do not love, 5 is LOVE it!
What do you do for work?
Areas outside work causing stress
Health Issues
Family
Finances
Current circumstances
Other
Any other current areas in life causing you stress?
How would you rate your stress or worry level on a scale of 1-10?
Eating Habits
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks do you typical grab?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc.)
How much do you think you spend on what you consume daily?
$15/day or $105/week
$20/day or $140/week
$25/day or $175/week
Other
What flavors are you MOST drawn to? (Mark as many as preferred)
Sweet
Savory
Coffee/Coffee Flavors
Chocolate
Spicy
Do you have any food preferences, requirements, or health considerations?
Personal Health
Current Weight: (We do MORE than look at scale, but this number DOES give insight to health, wellness, and what we are at risk for.)
Height:
In a perfect world, if you could NOT fail, how many pounds would you want to lose?
If not scale oriented, what would be your goal?
Current Conditions or Medications --check all that apply
Blood Pressure Medication
Cholesterol Medication
Thyroid Medication
Type 1 Diabetes
Type 2 Diabetes
Gout
Currently Pregnant
Currently Nursing
Currently on GLP-1 Medications
History or Gastric Bypass or Sleeve Surgery
Other
What has been the most difficult thing about losing weight (or changing habits) in the past?
How ready are you to make the changes in your life that your goal requires?
I'm just checking it out
1
2
3
4
I'm READY! I would do anything to get to a healthier place!
5
1 is I'm just checking it out, 5 is I'm READY! I would do anything to get to a healthier place!
Is there anyone in your life who you'd like to get healthy with?
If you're ready to see real change, let's find some time to talk about which of our programs would fit you best. When do you have available time in the upcoming week for a phone call to explore what this could look like for you? (Mark as many as available)
Monday afternoon
Tuesday afternoon
Weds afternoon
Weds evening
Friday morning
I need a Saturday appointment
On a scale of 1-10 (10 being the most), how ready are you to make changes to reach your goal?
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