Health Questionairre

Please fill out the form below to activate the daily email series for your 7-Day Reboot!

[contact-form][contact-field label=’Name’ type=’name’ required=’1’/][contact-field label=’Email’ type=’email’ required=’1’/][contact-field label=’Your Weight’ type=’text’/][contact-field label=’Measurements: Waist and hip’ type=’text’ required=’1’/][contact-field label=’Stress Level Survey’ type=’checkbox-multiple’ options=’3-5: moderate stress (healthy doses, not overwhelming),5-7: medium to borderline high levels of stress,8-10: high levels of stress’/][contact-field label=’Sleep Quality?’ type=’checkbox-multiple’ options=’I sleep soundly through the night,I fall asleep as soon as my head hits the pillow,I have a hard time unwinding when it is time to go sleep,I seldom sleep through the night,I wake up tired’/][contact-field label=’Eating Survey’ type=’checkbox-multiple’ options=’I eat healthy 80%25 of the time,I follow a Paleo diet,I eat a plant-based diet,I eat a diet full of whole and real foods,I am often on the go and I eat what is fast and convenient,I seldom eat %26quot;healthy%26quot; foods,I eat whatever is handy’/][contact-field label=’What is one wellness goal and why is it a goal?’ type=’text’/][/contact-form]