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Home
About
WHAT I OFFER
Services
Join The Team
TESTIMONIALS
Blog
Contact
Sign Up

EVALUATION

Home » EVALUATION

WELLNESS EVALUATION

Please take a few minutes to fill out your evaluation as completely and accurately as possible. Remember, this is your first step to changing your life. We have helped others just like you achieve amazing results and we look forward to doing the same for you!

Name*
First Last
Facebook Name*
Email*
Phone (including area code)*
Address (Street, City, State, Zip)*
Gender*
- Male
- Female
Age*
Height (FT IN)*
Weight (LBS)*
Who referred you?
How many pounds would you like to lose/gain, or what is your health goal?*
What have you tried before and why did it not work for you?*
Do you eat three meals a day?*
- Yes
- No
If no, which meals do you skip?
Do you snack? If yes, what do you snack on?
Do you have any food allergies or restrictions? If so, what are they?
How much water do you drink daily?*
What else do you drink? (tea, juice, soda, coffee, energy drinks )
Would you like to improve your energy levels?
- Yes
- No
When are you most tired?*
When are you most hungry?*
What time do you wake up and go to bed?*
Do you exercise?*
- Not at all
- Occasionally
- Regularly
If you do excerise, what types of exercises?
What do you typically eat for breakfast and what time?*
What do you typically eat for lunch and at what time?*
What do you typically eat for dinner and at what time?*
Where do you work and what are your work hours? Do you have any restrictions for breaks while at work?*
Do your days off from work wake hours and eating habits look different? If so, what changes with your eating habits?*
Do you or any family members suffer from health problems, such as:
- Diabetes
- High Blood Pressure
- Cholesterol
- Digestive/Constipation
- Migraines
- Depression
- Allergies
Do you perform a colon cleanse at least once every six months?*
- Yes
- No
Any additional Information you would like to share?
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Rebecca Amissah
Ph (510) 280-4292
info@rebeccaamissah.us

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