Health Breakthrough Review Form

First Name *

Last Name *

Email *

Date of birth *

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Current Health + Lifestyle

In your own words — how are you feeling lately (physically, mentally, emotionally)? *

Have you had any recent diagnoses, surgeries, or big life changes? *

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Daily Habits

How would you describe your current way of eating? *

I eat pretty well most of the time

I’m confused about what’s healthy

I tend to skip meals, snack, or eat on the go

I feel controlled by cravings or emotional eating

Please list what you eat on a typical day *

How would you describe your sleep right now? *

Restful and consistent

Interrupted or restless

Struggle to fall or stay asleep

I wake up tired

What does movement look like in your week? List types of exercise, how long, and how frequently *

How is your hydration? List what you typically drink in a day including water, alcohol, coffee and sugary/ energy drinks *

What does a typical day look like for you? List what you typically do from waking until sleep (including typical time you go to sleep/ wake up) *

How often do you feel stressed or overwhelmed? *

Rarely

Occasionally

Most days

Constantly

How often do you feel disconnected from your body or intuition? *

Never

Occasionally

Often

Almost always

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Deeper Layer

If you had to guess — what do you think is really behind how you’re feeling right now? (Encourages self-awareness + uncovers mindset patterns) *

What have you tried before (diets, programs, therapies, habits)? What worked or didn’t? *

Is there anything you know would help — but struggle to stick with? *

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Final Note

Is there anything else you want me to know before I record your video? *

Payment Here *

Health Breakthrough Review

AU$110

AU$50