Fire Shapers Health Questionnaire

Complete the questionnaire to a healthier you…

* indicates required

Best Email Address *

First Name *

Mobile Number *

Country *

State *

Male / Female *

Age Range *

What is your Current weight? *

What do you think is your IDEAL weight should be? *

At what age were you last at your ideal Weight?

What vitamins, shakes or superfoods do you take? *

How often do you cook Healthy Meals?

How often do you exercise?

What would you like to improve MOST w/this plan? *

Rate your energy level on a scale 1 – 10 (10 best) *

Rate your stress level (10 = Totally STRESSED) *

Tell us why you need to take action today.

How will your Life be Better by reaching your goal

What will happen if you don’t make a change?

Choose Your Fire Body Coach *

Back