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Health Assessment Form

Tell Us About Your Situation

This is not a generic form. This assessment helps us understand whether we're the right fit to help you, and whether you're genuinely ready to make a change. Please answer honestly.

Click the button below to start.

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Question 1 of 16

Section 1: 

First Name: (Required)

Email Address: (Required)

Question 2 of 16

What is your age range? (Required)

A

25-35

B

35-45

C

45-55

D

55-65

E

65+

Question 3 of 16

 

Section 2: 

What is your biggest health struggle right now? 

(Select all that apply)
A

Exhaustion and low energy

B

Brain fog and lack of mental clarity

C

Chronic pain or inflammation

D

Gut and digestion issues

E

Sleep quality problems

F

Stress and anxiety

G

Weight management

H

Hormonal imbalances

I

Recovery and muscle soreness

J

Other

Question 4 of 16

On a scale of 1-10, how much is this impacting your life? (1 Lowest & 10 highest)

Question 5 of 16

How long have you been dealing with this? 



 

A

Less than 3 months

B

3-6 months

C

6-12 months

D

1-2 years

E

2+ years

Question 6 of 16

Describe what's happening. What does a typical day feel like for you? 

Question 7 of 16

Section 3: What You've Tried

What have you already tried to improve your health? 

(Select all that apply)
A

Nothing significant yet

B

Different diets (keto, paleo, vegan, etc.)

C

Gym/fitness routines

D

Supplements

E

Traditional doctor/medication

F

Therapist or counseling

G

Alternative health practitioner

H

Lifestyle changes on my own

I

Other

Question 8 of 16

What worked (even a little) and what didn't?

Question 9 of 16

Section 4: Investment and Commitment (Critical Qualification)

Are you genuinely ready to invest in your health right now? 

A

Yes, I'm ready to make real changes

B

I think so, but I'm uncertain

C

I'm curious, but not sure about the commitment

D

I'm not ready yet

Question 10 of 16

What does "investing in yourself" mean to you?

Question 11 of 16

If real solutions were available, how much would you be willing to invest monthly?

(Select all that apply)
A

I need to know the price first

B

$100-250/month

C

$250-500/month

D

$500-1000/month

E

$1000+/month

F

This isn't about the money—I'm ready to invest what it takes

Question 12 of 16

What's your biggest concern about working with someone like me?

Question 13 of 16

If nothing changes in the next 6 months, how will that affect you?

Question 14 of 16

Section 5: Final Qualification

How did you find out about this? 

A

Google

B

Social Media (Facebook, Instagram, TikTok, Etc.)

C

Referral

D

Other

Question 15 of 16

What would need to be true for you to feel genuinely healthy? 

Question 16 of 16

On a scale of 1-10, how serious are you about making a change?

(1 - Least Serious & 10 - Very Serious)

Confirm and Submit