Name(Required)

First Last

Email(Required)

Phone (so that I can text you with your next best steps!)(Required)

What goals are you trying to accomplish within the next 6-12 months?(Required)

What have you already tried in the past to achieve those goals and why don’t you think it worked?(Required)

On a scale of 1-5 (1 = terrible; 5 = awesome), how would you rate your relationship with food?(Required)

On a scale of 1-5 (1 = no understanding; 5 = full understanding), what is your understanding of your body’s macronutrient and calorie needs?(Required)

Approximately how many diets have you tried in the last 1-5 years?(Required)

Have you been eating at caloric maintenance for the past 6 months?(Required)

Yes

I'm Not Sure

Can you give me an estimate of how many calories you consume in a day? If you're unsure, type "unsure."(Required)

How many grams of protein are you currently eating per day? If you’re unsure, type “unsure”.(Required)

How many grams of fiber are you currently eating per day? If you're unsure, type "unsure."(Required)

How many times do you strength train per week?(Required)

How much cardio do you do per week? Please include your daily step count.(Required)

On average, how many hours of sleep do you get each night?(Required)

On a scale of 1-5 (1 = zero stress; 5 = extremely stressed), how would you rate your stress levels throughout your day?(Required)

Do you struggle with any of these GI symptoms consistently? Please check all that apply.(Required)

Bloating

Gas

Constipation

Diarrhea

Acid reflux / heartburn

Burping after meals

Undigested food in stool

Light-colored or oily stool

Nausea

General stomach pain

Fullness for extended periods of time after meals

Food allergies / intolerances

Always getting sick

None of the above

Do you struggle with any of these hormonal symptoms consistently? Please check all that apply.(Required)

Irregular, painful, or heavy periods

Hair loss

Chronic fatigue / low energy

Brain fog

Skin issues (eczema, rosacea, acne, dry or oily skin)

Belly fat gain

Difficulty losing weight

Insomnia

Low sex drive

Mood swings

Headaches / migraines

Dark facial hair growth

Energy crashes

Infertility

Anxiety or depression

Joint aches / muscle soreness

Hot flashes

Cold intolerance

None of the above

Are you interested in working 1:1 with FFLA?(Required)

Yes

I'm Not Sure

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Let’s get to the root of your weight loss resistance and frustrating symptoms!