Total Body Transformation Intake Form

Start your journey here! Tell me a little more about you, your stuggles & your goals!

Name *

First

Last

Email *

What is your main health concern? *

What have you done in the past to work on this health condition? (include both alternative and traditional modalities.) *

What has proven effective? *

What is your current diet like? Please be specific; list breakfast, lunch, dinner, and snacks, as well as the times you eat. *

Are you taking any supplements? Please list what you take and what it is for. *

What would you like your health to be 30 days from now? How about 90 days from now? How would you feel if you got this result? *

What obstacles, challenges, and struggles do you come up with regarding diet/lifestyle? *

Which statement best describes your view about commitments to yourself? *

I make a commitment to myself only if I’m convinced that it really makes good sense to do it.
If someone else is holding me accountable for my commitments, I’ll meet them – but if no one knows except me, I struggle.
I bind myself as little as possible.
I take my commitments to myself as serious as my commitments to other people.

What do you hope to get out of our time together? *

What are 5 things you LOVE about your life? *

Name