Ideal Health Consult Application

So that we can make the most of our time together, please provide the information below and then select a date and time that is convenient for you.

First Name

Last Name

Email *

Phone *

Tell me your height and weight *

CURRENT HEALTH STATUS: Please check any current serious health conditions you would like to overcome *

Digestive Issues

High Cholesterol

Depression/Anxiety

Thyroid Condition

Autoimmune Condition

Diabetes/Pre-Diabetes

High Blood Pressure

Chronic Pain

metabolic condition (weight, inflammation, blood sugar)

Hormone Imbalance

NONE

OTHER

If you selected "OTHER" above, please state any other conditions not listed.

What are you top three health challenges/main complaints? *

How often does this bother you? *

Everyday

2-3x a week

Once a month

How long has it been going on? *

1-6 months

1-3 years

Over 3 years

When are you looking to start taking back your health? *

Today

Next Week

Next Month

What (or who) would prevent you from completing a health-rebuilding or weight loss program? *

Children

Spouse

Time

Self

Money

Fear

Job

Resources

CURRENT DIET: Current way of eating in the last 30 days. Examples: Organic, processed foods, fast foods, supermarket pre-made meals, vegan, vegetarian, standard american diet, Paleo, Keto, etc. *

How many times a day do you eat? What times of day do you eat? *

Are you taking any medications? Please list what you take and what it's for. *

What have you tried so far that has or has not worked? *

If you could reverse your health or solve many of your health complaints, how would your life be different? *

What obstacles, challenges and struggles do you face regarding diet/lifestyle? This is safe space to be honest with yourself and me. There is no judgment in your answers. *

Why is NOW the perfect time to invest in yourself and commit to your health in a new way you have never done before? *

Is there anything else you would like to add? *

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