Your Name (required)

Your Email (required)

What is your gender?

Are you currently working to improve your health? If yes, how?

What are your specific Health/Physique Goal(s)?

Rank your eating habits (10 = very healthy, 1 = poor)

Are you willing to check in with me regularly on our private Facebook page?

Do you currently exercise? And, if so, what kind of exercise?

What nutritional and/or exercise programs have you tried in the past?

Have you been diagnosed with any of the following conditions? Check all that apply:
Metabolic DamageDepressionHyper/HypothyroidBulimiaBi-Polar DisorderMenopause/PerimenopauseAnorexiaAnemiaAdrenal FailureDiabetesPhenylketonuria (PKU)HashimotosHemochromatosisInsomniaArthritisCancerCeliac DiseaseLeaky GutInfertilityIrritable Bowel Syndrome (IBS)SciaticaPost Traumatic Stress Disorder (PTSD)Anxiety Attention Deficit (Hyperactivity) DisorderAutismDissociative DisorderMSOtherNone

Are you currently taking any of the following medications?
Birth Control (of any kind)Hormone Replacement Therapy (Bio-identical or otherwise)Testosterone Anabolic SteroidsNoneOther (please specify below)

Do you have any exercise limitations, such as injuries or illness that I should know about?

Are you ready to change your health?

Is there anything else that you would like to share with me? Please type it below.