In Health Now Wellness Solutions, LLC

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Preferred Phone *

Preferred Email *

What is your preferred contact method? Phone
Email
*

When is the best time to reach you? Morning
Afternoon
Evening
*

Answering the following questions will help us get a good idea of your current eating habits.  This information will aid your Transitions coach in helping you make better food choices.

Answers for the following questions should be based on daily average intake of each item.

Daily Water Intake 0 Glasses 1-4 8oz Glasses 5-8 8oz Glasses More than 8 8oz Glasses

Daily Fresh Fruit Intake 0 Pieces 1-2 Pieces 3-4 Pieces 5+ Pieces

Daily Salad/Greens Intake Almost Never 1-2 cups 3+ cups

Daily Intake of Cooked Green, Leafy Vegetables Almost Never 1-2 cups 3+ cups

Daily Intake of Raw Vegetables Almost Never 1-2 cups 3+ cups

Daily Intake of Breads, Pasta/Rice, Potatoes Almost Never 1-2 Times 3-5 Times

Organic Foods Frequently Occasionally Almost Never

Daily Intake of Dairy Products Almost Never 1-2 Servings 3-5 Servings

Fast Food Frequently Occasionally Almost Never

Sugary Foods & Soft Drinks Frequently Occasionally Almost Never

Salty and/or Fatty Snacks Frequently Occasionally Almost Never

Multivitamin Frequently Occasionally Almost Never

Fish Oil Supplement Frequently Occasionally Almost Never

Calcium with Vitamin D3 Frequently Occasionally Almost Never

Other Supplements Frequently Occasionally Almost Never

Food Allergies (150 chars left)

The following section will give your Transitions Coach and idea of your lifestyle and diet history.  For each questions, please choose the answer that best describes your current lifestyle.

I exercise Frequently Occasionally Almost Never

I read labels on the foods I purchase Frequently Occasionally Almost Never

I get 8 hours of sleep Frequently Occasionally Almost Never

I take time for recreation Frequently Occasionally Almost Never

I overeat or binge eat Frequently Occasionally Almost Never

The following triggers my binge eating Stress Boredom Feeling Depressed

I feel sressed Frequently Occasionally Never

I have tried 'Diets' 5 or more times 1-4 times Never

Diet Results Lost Weight Lost, But Gained it back Did Not Lose

Please choose the priority level of each health goal below.

Increase Energy High Priority Medium Priority Low Priority Doesn't Apply

Reduce Mood Swings High Priority Medium Priority Low Priority Doesn't Apply

Lose Weight and Inches High Priority Medium Priority Low Priority Doesn't Apply

Improve Digestion High Priority Medium Priority Low Priority Doesn't Apply

Relieve Stress High Priority Medium Priority Low Priority Doesn't Apply

Lower Blood Pressure High Priority Medium Priority Low Priority Doesn't Apply

Improve Blood Glucose High Priority Medium Priority Low Priority Doesn't Apply

Control Appetite High Priority Medium Priority Low Priority Doesn't Apply

Control Cholesterol High Priority Medium Priority Low Priority Doesn't Apply

Reduce Joint / Back Pain High Priority Medium Priority Low Priority Doesn't Apply

Improve Sleep High Priority Medium Priority Low Priority Doesn't Apply

Reduce Allergies High Priority Medium Priority Low Priority Doesn't Apply

Please check any health challenge you have faced in the last month Headache
Sinus Infection
Hay Fever or Asthma
Stomach Upset
Diarrhea
High Blood Pressure
Lack of Energy
Diabetes
Inflammation
Arthritis Pain
Stressed Out

How many people do you know with similar issues? None
1-2 Others
3-4 Others
5 or more

If you were introduced to a solution, would there be any reason you would not be willing to start? Yes No

We offer classes at various locations in central Indiana including community centers, businesses and private homes.  The following information helps us schedule classes that are convenient for you, our client.  Please let us know what you think.

Please choose the town where you would most likely attend a class Bloomington
Brownsburg
Fishers
Greenwood
Indianapolis
Martinsville
Plainfield

If you were recommended to this site by a coach, please select the coach Amy Latka
Betsy Rabold
Christine Telthorst
Irene Greiner
Lisa Rector
Michele Fleming
Vickie Seidle

If you weren't recommended by a coach, how did you hear about us? (100 chars left)

The Transitions Lifestyle system is not just another fad.  This is guaranteed to work for you if you follow it.  Therefore, we only need clients that are absolutely serious about their health and losing weight.

We appreciate you taking the time to answer these questions.  A Certified Transitions Lifestyle Coach will be in touch with you in the next 24-48 hours.  Thanks!

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