Level 1First Name Email Address Level 2Age25 to 3535 to 4545 to 5555 to 6565 to 75Gender Male Female If Female: Hysterectomy Perimenopausal Menopausal Postmenopausal None of the Above Are you on hormone replacement therapy? Yes No If yes, which: Estrogen Testosterone Progesterone DHEA Testosterone Pregnenolone IUD Vaginal estrogen Other Level 3What are your health goals? Lose body fat/weight loss How many pounds would you like to lose?5 to 1011 to 2021 to 3031 to 4041 to 50more than 50What is your timeline for losing your extra weight?1 to 2 weeks2 to 4 weeks1 to 3 months3 to 6 months6 to 9 months9 to 12 months12 to 15 months15 to 18 months18 to 24 monthsas long as I needWhat diets have you tried in the past?Weight WatchersJenny CraigPaleoKetogenicLow-carbLow-fatSouth BeachAtkinsZoneEat Right for Your Blood TypeVeganLow CalorieIntermittent FastingMacrosDiet PillsNutri-SystemNoomOtherI currently have a thyroid condition Yes No 2nd choice Have more discipline Discipline Choice I tend to eat healthy during the week, but binge on the weekends I tend to eat healthy all day, but snack after dinner 3rd choice Sleep better I currently: Have trouble falling asleep Have trouble staying asleep 4th Choice Have more energy throughout the day Have more energy I am tired all day and night I am tired all day but wired at night I don’t function unless I have caffeine 5th Choice Have a better relationship with food Have a better relationship with food I am scared of gaining weight if I eat I have no willpower I suffer from uncontrollable cravings I restrict myself from eating food, but find myself binging I have a history of eating disorder 6th Choice Create your ideal body composition Have a better relationship with food Have toned muscles Lose Fat 7th Choice Build muscle Do you currently lift weights or strength train? Yes No How many times per week?8th Choice Improve strength and endurance What kind of exercise do you currently participate in? HIIT (High Intensity Interval Training) Cardio machines Weight training Walking outside Sitting on the Couch 9th Choice Clearer Skin I have: Cystic acne Minor acne Rosacea Hives Rash Itch 10th Choice Clearer thinking/less brain fog I have trouble with: Focus Memory Fatigue 11th Choice Better digestion I suffer from Bloating Constipation (don’t have a bowel movement daily) Diarrhea Reflux Smelly Gas Feeling very full after meals Skin issues 12th Choice Balanced hormones I have a lot of PMS symptoms Bloat Constipation Diarrhea Irritability Cramps Breast tenderness Headaches I am currently on hormone replacement therapy Estrogen Progesterone Testosterone DHEA Pregnenolone Other Check all that apply:13th Choice Stress management On a scale of 1-10, my stress level is: 1 2 3 4 5 6 7 8 9 10 14th Choice Less anxiety/depression Less anxiety I currently take medications to help Are you ready for lifestyle changes to be a part of your goals? Yes No I currently: Smoke cigarettes Drink alcohol Drink Alcohol Beer Wine Spirits Beers, Wine, Spirits Daily Weekly How Many?
