Help Us Help You!

Take this quick assessment to find out if one-on-one support is the right fit for you! 🌟 Sometimes, we all need a little extra love to reach our goals—whether it’s in fitness, nutrition, or mindset. This quiz will break down the areas where you might need a boost and provide insights to help you thrive. Let’s see how we can support your journey!

Results are posted at the end!

Full Name

Phone *

Email *

Address

Have you tried any weight loss/nutrition programs in the past? *

Yes

What is your biggest challenge with weight loss? *

Lack of motivation

Struggles with diet

No time for exercise

Medical conditions affecting weight loss

Tell us (in your own words) the top three things you dream about changing.

How often do you exercise *

Daily

3-4 times per week

1-2 times per week

Rarely or never

Do you have any dietary restrictions? *

Yes

How often do you drink Alcohol or Sugary Drinks?

Both Often

Alcohol Often

Sugary Drinks Often

Both Sometimes

Alcohol Sometimes

Sugary Drinks Sometimes

Both Seldom

Alcohol Seldom

Sugary drinks seldom

Are you willing to make long-term lifestyle changes for weight loss? *

Yes

Do you have any medical conditions that affect your weight? *

Diabetes

Thyroid issues

High blood pressure

pcos/endo

Other Issues not listed

None of the above

How soon do you want to start a weight loss program? *

Immediately

Within the next month

In the future, but not ready yet

Not sure

Are you open to professional guidance such as nutritionists, personal trainers, Therapists or medical weight loss programs? *

Yes

What type of weight loss and support are you most interested in? *

Personalized coaching

Meal planning & nutrition guidance

Fitness training & workout programs

Medical weight loss options

Pain managment Consults

Physcosynthesis Consults (mind set/Well being)

Tell us in your own words what you feel your health obstacles are and why you feel they have held you back.

what do you feel would help the most?

Type your answer here

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