Wellness Evaluation

This is a real check-in on where you are and where you’re headed.

We’re getting a clear snapshot of your nutrition and physical health so we can meet you where you’re at and help you move forward.

Take 6–7 minutes to answer honestly. The better the input, the more meaningful the next steps we can build together.

First Name *

Last Name *

Cell Phone *

Email *

Personal Snapshot

How did you first hear about this personalized coaching opportunity?

What are your ultimate/most relevant health goals?

Fat loss, muscle gain, better energy, look better, more confidence, wedding / travels coming up, etc.

What is your motivation behind this/these goals?

A strong WHY gets us through any HOW.

What diets, exercise plans, or programs have you tried in the past? What worked & didn't work for you? *

A strong WHY gets us through any HOW.

What best describes your current work status? *

If you work / if you're retired, are you enjoying this? *

Are you currently involved in any communities, clubs, gyms, teams, or social groups?

Have you ever taken or are currently taking supplements? What kind & have you been consistent? *

Describe your average/typical breakfast *

Describe your average/typical lunch *

Describe your average/typical dinner *

If you snack, describe your typical snack choices

How often do you eat out per week & how healthy are these choices? *

Describe your average/typical beverage habits *

water, coffee, tea, alcohol, soda, energy drinks, etc & how MUCH water per day

How may times do you exercise per week? *

How often do these activities make your sweat / short of breath? *

Where do you workout & what kind of workouts? *

Gyms, yoga studio, group workouts, pilates, HIIT, community runs, etc.

Do you have any accountability buddies supporting you / working out with you? *

How many hours do you typically get & what's the quality of your sleep? *

How will you know you're making progress on your goal(s)? *

When you're achieving this / these goals, how will you feel? *

On a scale of 1-10, how serious are you about your health & nutrition goals? *

Feel free to share WHY you gave this number

What questions or curiosities do you have right now?

Is there anything else you’d like us to know about you as a person?