Hi there!  Our top priority is you!

It is helping and serving you so you can overcome your health and weight issues once and for all.

If you found us online and are just looking for some free information, or you’re not too concerned about the state of your health (or weight), then we are not for you.

About Us:

• We are for the person that is serious about achieving their health and/or weight goals.

• We dedicate ourselves fully to you, the person that needs and wants help.

• You will receive amazing care and customer service from us.

• We will walk with you side by side to help you however we can.

• Others not too concerned about their weight or health please do not fill out the below form.

• We do not mean to be rude or disrespectful in any way.  We just have to give ourselves completely to those that really need and want help.

Instructions: Please fill out the below health evaluation.  If you are experiencing more than one symptom on the list then please check all that apply.  We will contact you ASAP for a free consultation.

• 1. Which one of the below bodies do you most look like?
  
  • A
  • B
  • C
  • D
• 2. Which of the following do you experience 2 or more times per week?
  • Muscular or joint pain
  • Pain from arthritis
  • Everything hurts or aches
  • A feeling of being swollen
• 3. I have sleeping problems
  • 1 to 2 times per week
  • 3 to 4 times per week
  • More than 4 times per week
• 4. Mark any of the foods that you crave 3 or more times per week.
  • Salt
  • Sugar and/or carbs
  • Fats
  • Other
• 5. Which of the following do you experience 3 or more times per week?
  • Anxiety
  • Depression
  • Panic attacks
  • Feeling overwhelmed or stressed
• 6. Which of the following do you experience 2 or more times per week?
  • Problems remembering things
  • Brain fog
  • Can't focus and/or concentrate, distractable
• 7. Which of the following are you aware of
  • My hair is thinning
  • My nails are weak
  • I have high cholesterol
  • I have high blood pressure
• 8. I have an autoimmune disease
  • Yes
  • No
• 9. Which of the following do you experience at least twice a week?
  • Heartburn and/or reflux
  • Constipation
  • Bloating
  • Stomach or intestinal pain
• 10. Check all that apply
  • I experience hot flashes and/or night sweats
  • I have problems with the regularity of my menstrual cycle
  • I have PMS
  • I have a reduced sex drive
• 11. Where are you in your health and weight loss journey?
  • I don't really care about my health or weight
  • I'm ready to get healthy and lose weight once and for all
• 12. If being overweight is a concern, how much weight would you like to lose?
• 13. Please tell us in detail about the weight and/or health problems that you have struggled with in the box below.

• Your Information

• Name*
  First Last
• Email Address*
  Enter Email Confirm Email
• Phone*
• Phone (confirm phone number)*
• Please Check this Box for Texting Consent
  Can we please text you in order to get you scheduled for your free consultation? It makes life much easier. Check box for yes 🙂
• Best Day of the Week to Call
  MondayTuesdayWednesdayThursdayFridaySaturdaySundayAny Day
• Best Time of Day to Call
  MorningAfternoonEveningAny Time
• Address*
  Street Address City State / Province / Region ZIP / Postal Code
• Gender*
  • Male
  • Female
• Age*
• How did you hear about us
  Google SearchTikTokInstagramYouTubePinterestFacebookYahoo or Bing SearchReferral from Friend or FamilyEmailOtherInsert in mail or newspaper
• If other, please let us know where:

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Disclaimer, Terms and Conditions

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