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Andrew Coaching Intake Form

Welcome to the Longevity Solution Plan!

Congratulations on taking the first steps towards YOUR Healthy Journey and Welcome to the Longevity Solution. I want to help you find the incremental steps to help you start your journey to  a healthier you.

Andrew

Let's do this!

Start

Question 1 of 12

What are your current Health Concerns?

List your Top 3 Goals for the Next 6 months

It's important to take small steps towards your short term to long term Goals

Question 3 of 12

What are your Top 3 Goals for your 1st Month?

Question 4 of 12

What are your top 3 goals for 3 months?

Question 5 of 12

What are your Top 3 Goals for 6 months?

Question 6 of 12

Do you have difficulty Losing weight or Gaining weight?

A

I have problems losing weight

B

I have problems gaining weight

C

I don't have any weight problems

Question 7 of 12

How many Bowel movements do you have a day?

A

I don't have bowel movements every day

B

I have 1 bowel movement a day

C

I have 2-3 Bowel Movements a day

Question 8 of 12

How many meals do you eat a day?

A

2 Meals

B

3 meals

C

4-5 meals

D

Lost count, I snack throughout the day

Question 9 of 12

Do you have any stress in your life? 

(Select all that apply)
A

With your workplace with Colleagues or your Boss

B

With your Own Business

C

With your Spouse

D

With your Children

Question 10 of 12

How Many hours of sleep do you get per night?

 

Question 11 of 12

Do you want to learn more about:

(Select all that apply)
A

Finding your ideal body weight

B

Have a clearer mindset

C

How your body can heal itself

D

Have more endurance and stamina

E

Be stronger with greater coordination regardless of your age

F

Slow down the aging process

G

Living a long healthy life keeping up the physical activity during recreation and family events with your children or grand children

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