Name *
E-Mail *
Phone
Height *4‘95’05‘15’25‘35’45‘55’65‘75’85‘95’105‘115’126‘06’16‘26’36‘46’56‘66’7+
Weight (lbs) *
Sex *MaleFemale
Date of Birth *
How many ounces of water do you drink per day? *
Do you add anything to your water?YesNo
If so what?
Which of the following do you drink?
Water
Soda
Juice
Coffee
Energy Drinks
Alcohol
Tea
Milk
Do you Exercise? *NoYesSometimes
Are you currently on an eating plan? NoYesSometimes
If so which plan?
Do you feel tired, run down, and out of energy? *NoYesSometimes
Do you enjoy your work? *NoYesSometimes
Do you feel Stressed? *NoYesSometimes
What is your goal? *
What past methods failed you to reach your goals? *
How fast do you want to reach your current goals? *2 Weeks1 Month6 Weeks2 Months3 Months6 Months1 Year+
Do you suffer with pain, inflammation, or injuries?
How did you hear about us?
Facebook
Instagram
Yelp
Groupon
Referral
Other
What is the most important element in deciding to use our services:
Effectiveness (your results)
Time (how fast you get results)
Affordable (what we charge)
Service (how we respond to your needs)
