Health & Lifestyle Clarity Form

This form helps me understand your current health situation.
There is no obligation to join anything.

Section 1 of 6

Basic Details

Full Name* WhatsApp Number* WhatsApp number must be exactly 10 digits City & State* Date of Birth* Age* Gender*

Health Goal & Background

What is your primary health goal right now?*

Weight loss Weight gain Hormonal balance Low energy / fatigue Digestion issues Lifestyle discipline Overall health improvement

How long have you been facing this issue?*

Current Reality (Reflection Section)

How would you describe your current lifestyle?* What do you feel is your biggest challenge right now?*

Lack of consistency Emotional eating Stress Low energy No proper guidance No support system Confused with too much information Time management

Readiness & Mindset

On a scale of 1–10, how important is improving your health for you right now? (1 = Not important, 10 = Extremely important)* Health importance score must be between 1 and 10 Have you tried anything earlier to improve your health?*

Communication Process

I usually connect with form responses between 4:00 PM – 5:00 PM (IST).Are you comfortable with this time?* Which language are you comfortable with?*

Kannada English Hindi

Open Expression

Is there anything else you would like me to know about your situation? (optional)

Thank You 🙏

Thank you for sharing your details.

I’ll review your responses and reach out only if I feel I can genuinely support you.

Please note: Not everyone is taken forward for a clarity call.

One quick question (optional)

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