Client Health Questionnaire

Please tell me a little about yourself so I can serve you better.

Your Name (required)

Your Email (required)


Your Age

Your Current Weight:

Your Ideal Weight:

1. How long have you been struggling with your weight?
Less than 5 years5-10 yearsDecadesMy whole life

2. What do you feel is the BIGGEST obstacle to achieving your ideal weight?

3. What are you CURRENTLY doing to lose weight? Are you getting results?

4. What weight loss methods have you tried in the PAST?

5. Aside from excess weight, do you suffer from any other health challenges?

6. Are you on any pharmaceutical medications? If so, please list medications and conditions being “treated”.

7. Why do you want to lose weight? (Please describe how your weight is affecting you physically, mentally/emotionally, professionally and/or socially.)

8. Of all the reasons you want to lose weight, what is your #1 biggest MOTIVATION?

9. On a scale of 1-10, how URGENT is your weight/health situation? (1=not urgent at all 10= extremely urgent)

10. The Deep Personal Transformation that comes with attaining your ideal weight requires an investment of time, money and energy to make it happen. Please indicate your ability and willingness to invest in yourself:

TIME Investment (select one):
I am super busy. I have very little time to invest in taking care of myself.I have a lot on my plate, but I am able to organize my schedule to create time for myself.My health and losing weight is my #1 priority, and I’m willing to invest however much time it takes.

FINANCIAL Investment (select one):
I am on a very limited budget and/or it is difficult for me to spend money on myself.Finances are tight, but I understand the importance of investing in my health and can set aside funds to to so.Money is not an issue for me. I have the financial resources to invest in achieving the best results possible.

ENERGY Investment & MOTIVATION (select one):
I feel very unmotivated to do much of anything these days. I really want to lose weight and will do my best to achieve this.I am massively motivated to lose weight and transform my life, and I will do whatever it takes to make it happen.

11. Imagine this - You are able to finally achieve and maintain your ideal weight, get your energy and vitality back, free yourself from the potential diseases, medical bills and suffering of being overweight, and be empowered to step up in life and shine your light to the world. How would your life change? What is this Life Transformation worth to you? (select one)
A few hundred dollarsA few thousand dollarsPriceless. Life is short and I'm ready to to live it fully!

Thank you. My assistant or I will call you at the time you chose. Please commit to your appointment by typing this sentence in the box below: "Yes, I realize you are investing your time and energy in helping me - free of charge - and I promise I will answer the phone for my Weight Loss Breakthrough Session when I’m called."

Thanks! I look forward to speaking with you soon.

~ Siddheshwari ~