Reset program screening form

Reset 4 week program

"Reducing brain fog, bloating & weight - to feel good again"
Personal Information
Full Name *

Prefix First Name Last Name
E-mail *
You will now be added to the healthy tips and information list
Mobile Number *

Area Code Phone Number

Address *

Street Address
Street Address Line 2
City	State
Post Code	Country

What are your top 3 reasons for wanting to partake in the Reset program?
What diets/eating plans or health programs have you tackled before?
What has worked for you and why? (enjoyed the food, organized, variety of workouts.)
What hasn't worked for you and why (to complicated, no family support, workouts too hard, too much running, lack of support)
What is your main concern about your health at the moment?
What are you afraid of when it comes to diet and exercise programs?
eg. do you not enjoy stiffness after training, do you get anxiety feeling you have to keep up with others in the gym, do you self sabotage your food after seeing good results, do you overthink the food aspect?
What is your current diet like? Is it full of a variety of food, or do you eat the same sort of food each week? Give example of a daily food diary.
Please do not alter anything - I need to know what you currently have (there is no judgement in this program).
On a scale of 1-10, how much are you willing to commit to Reset? (1 not being willing to change - 10 being definitely willing)
Do you sleep well? Do you work shift work? etc
If you wake during the night please what time do you wake, do you fall back to sleep easily? Do you get to sleep easily, do you wake tired?
What do you want most out of this program?.
Out of the 4 pillars of health, what do you need to work on the most?

Sleep Stress Nutrition Movement/exercise
What type of essential oil blend would you like to support you through this program and beyond.. select two..

Uplifting Mood swings Restful/sleep Reduce Anxiety Cease cravings PMS Digestion/Bolating
What is your best learning method?

Reading Listening Watching Other
These are my group times in the gym - please select what times suit you.

Monday 6am Monday 8.30am (after school drop off) Monday 4.30pm onwards Tuesday 8.30am (after school drop off) Wednesday 6am Wednesday 8.30am (after school drop off) Wednesday 4.30pm onwards Friday 6am Friday 8.30am (after school drop off) Saturday 7am - 7:30am
If you have any special requests/concerns/prior injuries or anything else I need to know about please enter these below.
Should be Empty:

Reset 4 week program

Personal Information