Name

Email Address

Date of Birth

Height

Weight

Current medications; if you have not been prescribed any medications, enter "none."

Current supplements; if you do not take supplements, enter "none."

List your top 4 or 5 symptoms.

Have you had your gallbladder removed? Enter "YES" or "NO."

Have you have your thyroid removed? Enter "YES" or "NO."

Do you have any anaphylactic allergies? Enter "YES" or "NO."

Are you willing to consume animal products, if necessary, to improve health?

What else have you tried to help you improve your health? (provide a list)

What, specifically, are you wanting to achieve? (e.g.: lose weight, have more energy, etc.)

What do you think is stopping you from achieving your goals and improving your health?

Be 100% honest: on a scale of 1 to 10, how committed are you to doing whatever it takes to solve this problem? ( 10 being the most committed. )

Why is this call important for you? Having a MAJOR reason why is imperative to improving your health. (E.G: I need to lose 30lbs and improve my energy so that I can be here and enjoy my grandkids.)

Do you feel that you’re on the right path to achieving your health goals? If so, why aren’t you where you need to be?

How much are your health issues/symptoms impacting your life? ( 10 is Significantly Impacting My Life. )

What is your #1 fear when it comes to your health?

What do you believe is the cause of your health issues?

Additional Comments