Current Wellness Snapshot

My energy is consistent throughout the day

Needs Attention

Developing

improving

Strong

Thriving

I sleep well most nights

Needs Attention

Developing

improving

Strong

Thriving

I make healthy nutrition choices consistently

Needs Attention

Developing

improving

Strong

Thriving

I exercise regularly

Needs Attention

Developing

improving

Strong

Thriving

I manage stress well

Needs Attention

Developing

improving

Strong

Thriving

I recover well from workouts and daily demands

Needs Attention

Developing

improving

Strong

Thriving

I am satisfied with my current body composition

Needs Attention

Developing

improving

Strong

Thriving

I feel physically healthy

Needs Attention

Developing

improving

Strong

Thriving

I feel mentally focused and productive

Needs Attention

Developing

improving

Strong

Thriving

I am confident in my ability to improve my health

Needs Attention

Developing

improving

Strong

Thriving

Goals & Readiness

What is your primary health goal right now? *

Lose Weight

Improve Nutrition

Improve Gut Health

Increase Energy & Overall Wellness

Improve performance

Optimize Health & Longevity

Which statement best describes what you're looking for right now?

I'm looking for information and education before making a commitment.

I want a personalized nutrition plan and clear direction.

I want coaching, accountability, and ongoing support.

I want a comprehensive strategy focused on optimizing my health, performance, and wellness.

If you had the right plan and support, how soon would you like to begin?

Immediately

Withing the next 30 days

Within the next 90 days

Just exploring right now

Challenges & Obstacles

How long have you been working towards this goal?

Less than 3 months

3-12 months

1-3 years

More than 3 years

Rate your current nutrition habits

Excellent

Good

Fair

Poor

Rate your energy levels?

Excelent

Good

Fair

Poor

Rate your digestive health?

Excellent

Good

Fair

Poor

Are you confident that you can reach your goals on your own?

Very Confident

Somewhat Confident

Not Very Confident

I've tried may things without success

What has been your biggest obstacle? 26yws

Lack of consistency

Lack of time

Lack of knowledge

Low energy

Digestive issues

Stress and recovery

I don't know what's holding me back

Commitment & Contact Information

How likely are you to follow through if provided with a personalized plan and expert guidance?

Not at this time

Possibly

Likely

Absolutely

How important is achieving this goal?

Somewhat Important

Important

Very Important

Extremely Important

Which statement best describes your current situation?

Exploring Options

Gathering Information

Ready to Make Changes

Ready to Start Now

On your own, how confidnet are you that you can reach your goals on your own? 13oir

Very Confident

Somewhat confident

Not very confident

I've tried many approaches without lasting success

If you believe the solution is right for you, are you willing to invest in improving your health?

Not at this time

Possibly

Likely

Absolutely

Full Name

Email *

Phone *

By checking this box, I consent to receive non-marketing text messages from 139FIT Performance and Wellness. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from 139 FIT Performance and Wellness at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

Wellness Score

Maximum score = 50.