STEP 1: Vana Health Application Form
First Name
*
Last Name
*
Email
*
Phone
*
Instagram
What city do you live in?
*
Age Range
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Under 25
25 - 34
35 - 44
45 - 54
54+
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How did you find out about Coach Silvi and Vana Health?
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Facebook
Instagram
Google
Referral
Other
If Referral or Other
___________________________________________
1. What are your main health and wellness goals?
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Fat loss
Improve gut health
Balance hormones
Increase energy
Improve mental clarity
Build strength
2. Why are you interested in working with us?
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3. What challenges are you currently facing in achieving your health goals?
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Fatigue
Stress
Hormonal imbalances
Digestive issues
Lack of motivation
Limited time
4. Do you have any of the following health concerns?
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IBS or digestive issues
Hormonal imbalances
Skin issues
Menstrual cycle irregularities
Bloating or inflammation
None of the above
5. Are you currently under any medical care or taking medications that may affect your health journey?
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6. Have you worked with a health or fitness coach before?
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Yes
No
If YES - what worked or didn’t work for you?
7. How much time can you realistically dedicate to your health journey each week?
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Less than 2 hours
2-5 hours
5-10 hours
10+ hours
8. Do you feel ready to commit to a tailored program?
YES - 100% I need to change
I'm nervous
9. Would you like to be part of a supportive community group with other women on similar journeys?
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Yes
No
10. What aspects of community support appeal to you?
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Sharing progress and challenges
Group discussions and webinars
Motivational content
Networking opportunities
11. Is there anything else you'd like us to know about you or your goals?
Submit Now