Personal Health Survey

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Personal Health Survey

Please fill out the following survey and press Submit.
Your responses will be sent directly to Karrie Gregson and treated confidentially.

If you prefer, you may print out the survey and deliver in person.

Print a hard copy

* Indicates required field

Name *

First

Last

Street Address *

City *

Postal Code *

Phone Number (Cell or Home) *

Phone Number (Work) *

Email *

What do you really want? Here are a few questions that are very important to start so I can know you better and help you more.
I then ask for more specifics on your eating and lifestyle.

What is your ultimate goal? Be specific and descriptive. If you could do or have absolutely anything, what would that be? What would make you shine? What really lights you up? *

Why? What makes you uncomfortable about this the way it is now? How do you really feel about this? How long have you felt this way? *

Do you have something coming up to work towards? Long term or short term? *

30 Day Goal *

90 Day Goal *

1 Year Goal *

On a scale of 1-10, how important is it for you to reach these goals? *

How would you feel if A) You were right now in your desired situation (goal)..if you were living it now. What does it feel like? *

How would you feel if B) Things never changed and you stayed right where you are and in 1 year..you are in the exact same situation? *

In addition to your desired outcome, what other specific benefits would you love to enjoy?

Choose Any *

Detoxification Increased energy Sugar balance Better athletic performance Improve a relationship Less discomfort Enhanced mental clarity Build lean muscle mass Improved digestion Improved mobility Better sleep Get rid of a bad habit Decreased stress levels Other

Untitled *

How many 8 oz servings of each of the following do you drink each day?
Please also give a brief description of a typical day of eating in breakfast, lunch, dinner

Decaf Coffee *

Alcohol *

COFFEE *

Juice *

Diet Pop *

Water *

When you drink water, is it tyically Bottled, Tap, or Filtered? *

Soda Pop (non-diet) *

Breakfast *

Afternoon Snack *

Lunch *

DINNER *

Want to get in touch with Karrie?

Click here to contact Karrie Gregson.

Want an off-the-beaten-path vacation?
Alpenboxx has got you covered!
Contact Karrie Gregson to learn more.

Email karrie@alpenboxx.com
Canada (519) 744 3232
Austria +43 6643882976