Work With Me

Are you ready to ditch the short-term diets in exchange for long-term success?
Do you want to achieve your very best health? Are You Looking for a Solution?

Getting Started Is Easy.

Take my Health and Lifestyle Questionnaire

407-620-2315 | Beth@blueprint4health.com

Health and Lifestyle Questionnaire

Name *

Email Address *

Phone *

How much weight do you want to lose?

What weight loss programs or methods have you tried in the past?

What do you struggle with most in terms of eating and nutritions: 

What are your prime motivations for wanting to improve your health at this time? 

Do you have any health issues or concerns you’d like to address?

Do you have any food allergies or sensitivities?

How much water do you drink daily?

How many times to you dine out or pick up fast food during the week? 

How much do you think you spend daily on food, drinks and snacks?

Do you exercise regularly? If so, what type of exercise and how often? 

On a scale of 1 to 10 (10 being highest), how do you rate your stress level on most days? 

Selected Value: 0

On a scale of 1 to 10 (10 being highest), how do you rate your energy levels on most days? 

Selected Value: 0

How many hours of sleep do you typically get per night?

On a scale of 1 to 10 (10 being highest), how important is it to you to achieve your health / weight loss goals right now?

Selected Value: 0

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