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Tafiq's Metabolic Screening Application

Please fill out each section honestly and with complete detail. 

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Question 1 of 21

Name?

Question 2 of 21

Email?

Question 3 of 21

Mobile Phone?

Question 4 of 21

Age?

Question 5 of 21

Your biggest health and fitness challenge? (please explain in detail)

Question 6 of 21

Are you willing to follow the nutrition, fitness and lifestyle recommendations of a coach to overcome those challenges (including daily physical activity and consuming mostly home cooked meals)?

Question 7 of 21

With your job, are you primarily...

A

Sedentary

B

Active

C

I do not work and I'm pretty sedentary

D

I do not work but I'm pretty active

Question 8 of 21

Do you own dumbbells or any other exercise equipment? (please list all)

Question 9 of 21

If you could eat one food with no negative health effects for the rest of your life what would it be?

Question 10 of 21

Are you currently suffering from any hormone or metabolic imbalances that you are aware of (i.e. adrenal, thyroid, digestive disorders, menopause, andropause, pituitary, etc…)? 

A

Yes

B

No

C

Not sure

D

New Choice

Question 11 of 21

If yes, please explain (in detail)

Question 12 of 21

Are you willing to commit to changing the way you eat to reach your goals?

A

Yes

B

No

Question 13 of 21

Are you married or have a significant other? If so, how long have you been together?

Question 14 of 21

Will you need to confer with your spouse or significant other prior to signing up for the program?

A

Yes

B

No

Question 15 of 21

What are you willing to invest in to a customized coaching program to achieve your health and wellness goals?  

A

$669 - $999

B

$2199 - $2499

C

$1299 - $1599

D

$999 - $1299

E

$1899 - $2199

F

$1599 - $1899

Question 16 of 21

Have you invested in your health and fitness in the past?

A

Yes

B

No

Question 17 of 21

If yes, how did you like the experience?

Question 18 of 21

Do you have children? If so, how many and what are their ages?

Question 19 of 21

On a scale from 1-10, 10 being "I'M READY LET'S DO THIS". How ready are you to commit to transforming your health?

Question 20 of 21

 If you are not at a 10, what would it take to get you to a 10?

Question 21 of 21

Why Should I consider you for my custom coaching program?

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