Ultimate Body Reset - Intake Form

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Ultimate Body Reset®

Fill Out Your Intake Form

Tell us a little about yourself so we can personalize your program experience.

What’s your goal?

What’s the main obstacle to achieving your goal?

What’s your ideal result after finishing the program?

Are you currently managing any health condition through a diet? Has the doctor told you to change how you eat?

Current weight

Desired weight

Do you follow any specific diet?

Are there any foods you strongly dislike?

Do you have any allergies or sensitivities we should know of?

Do you often have cravings for sugar or processed food?

Do you experience bloating or digestive discomfort?

Do you often experience brain fog?

Do your energy levels drop after meals?

Do you have any skin issues?

Do you often feel anxious?

Do you have any problems sleeping?

Do you experience challenges planning meals for the week?

Do you find it difficult to find tasty healthy recipes?

Your cooking skills

I never cook

Beginner

Amateur

Pro

How many people are you cooking for?

How much time can you allocate to making meals?

20 mins a day

2 hours per week

4+ hours per week

Other

Where do you buy your groceries? What’s the name of the store?

Do you know your weekly budget for food?

Are you planning to buy kitchen equipment? How much are you open to invest in new healthy habits?

Do you have an oven?

Do you have a blender?

Do you have a food processor?

Do you have a juicer?

Do you have an airfryer?

Do you have a slow cooker?

Date of birth

How do you describe yourself?

Male

Female

Other

Location

Would like a personalized menu based on your lab tests and doctor’s guidance? It’s an additional cost

Yes

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