"Take Charge of Your Health"
3 Minute Evaluation
Name
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Email
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How Fulfilled are you with your OVERALL HEALTH on a scale of 1-10
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1 = I’m sick and tired of being sick of always falling short of my personal standards.
10 = I’m realizing I don’t even need to fill out this evaluation because I am so fulfilled with meeting ALL my personal standards!
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If your OVERALL HEALTH was closer to ideal in 6 months, what would you have changed? Mark the boxes below that most resonate with you! *
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I would have lost weight and met my ideal weight goal.
I would have diminished inflammation and pain in my body.
I would have eliminated or greatly diminished processed food, sugar, and any addictive substances.
I would have followed through with an ideal exercise & healthy meal plan.
I would have eliminated some or all of my prescriptions.
I would have made significant changes that keep disease from manifesting in my body.
I wouldn’t allow distractions and other’s agendas to interrupt my health & fitness plan.
I would have elevated my belief in myself, vision of my ideal health and followed a reasonable plan that was practical and built momentum over time.
I would have had support from friends, family and experts that empowered and inspired me to stay true to my health and fitness vision.
I would have become clear about the plan & process. I would have challenged my state of being overwhelmed and taken time to research or find a program that mapped out the process for me!
How fulfilled are you with your PHYSICAL APPEARANCE on a scale of 1-10?
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1 = I look the worst I have ever looked and have no idea what to do about it.
10 = I look exactly as I have always wanted to look! No improvements wanted at all!
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What’s important to you about your PHYSICAL APPEARANCE? Mark the boxes below that most resonate with you!
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My appearance doesn’t matter as much to me as being healthy. I mostly want to feel healthy and make choices that don’t have me feel bad about myself.
My weight is a concern, and I am interested in mapping out a way to release unwanted pounds.
I want to look and feel much better. I’ve taken my health for granted for way to long. I don’t really know where to begin and need help designing a plan that inspires me to take action and achieve my ideal fitness and health goals.
I don’t feel attractive. I want to feel attractive and increase my confidence.
I want to increase my sexual vitality!
I’m getting older and haven’t made fitness a priority. I want a fitness plan that resonates with me and follow through with it.
I am at a point where I must improve my meal and fitness plan.
I am ready to CRUSH my fitness & health plan and get my body in the best possible shape of my life!
I have been in an accident(s) that has prevented me from being physically active. I must find a customized program for fitness that I am comfortable with and that will help me prevent further injury.
What’s important to you about your PHYSICAL APPEARANCE? Mark the boxes below that most resonate with you!
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My physical appearance is important to me and I am ready to make a change.
My health is actually way above average, and I want to take it to the next level.
My health & fitness has become stagnant, and I feel stuck. I don’t know where to go from here, and I need help with how to proceed.
I have taken my health for granted, and I’m fearful of getting sick or worse.
My health has affected my sexual wellness. I want to look better, feel better, and increase my sexual vitality.
My health has affected my self-esteem. I feel insecure and unworthy. I want progress with my health & fitness to elevate my confidence.
I have a serious health condition and must take responsibility for what I can control. I want clarity and to feel powerful about the choices I am making to diminish my current health condition.
I need help figuring out how to create healthy meals for myself and/or my family.
Because I am getting older I really want to get in front of the aging process. It’s all about prevention for me.
How committed are you to changing your health on a scale of 1-100
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Is there ANYTHING ELSE you would like to add?
