Health Evaluation – Body Temple LLC

Health Evaluation

"Take Charge of Your Health"
3-Minute Evaluation

Name*
First Last
Email*
How Fulfilled are you with your OVERALL HEALTH on a scale of 1-10*
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!
1 2 3 4 5 6 7 8 9 10
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! **
- 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?*
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!
1 2 3 4 5 6 7 8 9 10
What’s important to you about your PHYSICAL APPEARANCE? Mark the boxes below that most resonate with you!*
- 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 are your compelling reasons you want to change your health? Mark the boxes below that most resonate with you!*
- 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.
If you were to make empowering decisions that significantly improved your health in 6 months, what would they have been?*
- 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 people’s agendas to interrupt my health & fitness plan.
How committed are you to changing your health on a scale of 1-100*
Is there ANYTHING ELSE you would like to add?
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Why Body Temple

Our Mission is to transform lives by offering customized wellness plans, innovative educational programs, and natural products that set a global standard for purity and quality!

Disclaimer

*These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease.

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"Take Charge of Your Health" 3-Minute Evaluation

Why Body Temple

Disclaimer

Major Credit Cards Accepted

"Take Charge of Your Health"
3-Minute Evaluation