Cart
0
Wellness Peptides
The Center Studio
Book Consultation
Ionic Foot Detox
Intolerances Test
Blog
Solle
Learn
Cart
0
Wellness Peptides
The Center Studio
Book Consultation
Ionic Foot Detox
Intolerances Test
Blog
Solle
Learn
Barefoot + Balanced AND Zenith Test Group Intake Assessment
Name
*
First Name
Last Name
Email
*
Initial Assessment
I'm excited to share information + techniques to support your wellness. Please take a few minutes to answer the questions so I can have a better idea on how to best support you! START BY SELECTING THE AREAS OF HEALTH YOU WOULD MOST LIKE SUPPORT IN:
Mindset Shift
Nutrition
Energy
Mental Clarity/Brain Fog
Weight Loss
Movement/Mobility/Exercise
Please rate where you are with each of the following
Positive Mindset: I can see the positive side of most situations + find expressing gratitude easy.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Balanced Nutrition: I find it easy to eat in a healthy way that supports my body's functioning.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Hydration: I drink at least half of my bodyweight in ounces (for example: weigh 160lbs, drink 80oz of water) daily.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Sleep: I get quality sleep most nights for 6+ hours.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Movement: I get in purposeful movement for at least 30 mins daily.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I sit down most of my day each day.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I get headaches often.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I eat enough healthy calories daily.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I eliminate my bowels daily.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I have a hard time waking up when it's time.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I suffer from aches and pains regularly.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am open to learning new healthy behavior practices.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am open to adding vitamin/mineral supplementation to my nutrition.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am good at regulating my nervous system.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
How much weight/body fat would you like to lose in 8 weeks?
5-15 lbs
15-35 lbs
35-50 lbs
50-75 lbs
100+ lbs
Please note your beginning stats here (weight, measurements) and describe any additional information you'd like to share with me about your current mind/body health and any specifics you'd like support with or questions you have.
Thank you!
