HealthCoachRoger.com


Your Health Profile: Tell Me About You

Congratulations on your curiosity in the program and concern for your health! Please continue and take just a minute to complete this form. It will be your first step on your path to optimal health.

Your responses to this questionnaire are completely confidential and will not be shared with anyone. After I review your responses, I'll be contacting you. Usually within about 24 hours. If you're ready to start the program (or have questions) and would prefer to speak to me sooner, that's o.k. too. Please call Roger at (877) 977-7080.

First Name:

Last Name:

Email Address (required):

Phone:

I prefer to be contacted by:

email     phone

Your Current Height:

 

Your Current Weight:

Age:

Birthday:

   

Sex:

male   female

Are you currently taking any medication:

yes     no

Do you have any allergies:

yes     no

Have you been diagnosed with Diabetes:

yes     no

Do you have high blood pressure:

yes     no

Do you have high cholesterol:

yes     no

Do you have other health related conditions:

yes     no

Have you tried other weight-loss programs:

yes     no

What is your target weight:

What is your #1 reason
for wanting to lose weight:

On a scale of 1-10, how motivated are you:

 (be honest)

were you referred by someone,
if so, please tell me who
(they will receive a referral credit)

yes     no
if so, who:

Comments:

 

 

 


Roger Jackson, Certified Health Coach, ID# 30074176 / (877) 977-7080
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This program offers a fast, safe and affordable way to lose weight and get healthy. This program is doctor recommended but not intended to take the place of the medical advice from a trained medical professional. Consult your physician before beginning a weight loss program. An independent or Certified Health Coach is not a substitute for a physician or qualified medical practitioner.