Please provide the following contact information:
On a scale of 1 to 10 (1 = low and 10 = high), how important is it to me to
immediately improve my health?
I am currently on prescription medications or under medical supervision.
If you selected yes above, please describe what
medications you are on and for what conditions. Please be as descriptive as
possible. This is very important!
I am currently experiencing the following symptoms:
(Please check all that apply)
How often do I consume the following per week?
How would I rate my current level of motivation and discipline to accomplish my
Where do I feel I am in each area below on a scale of 1 to 10? (1 = very poor
and 10 = very good)
|Overall Physical Health|
|Body Fat %|
will succeed with my Isagenix Program to become healthy, clean, and lean.
My ultimate goal is to reach my target weight of
pounds and to start by losing
pounds by this date:
My current weight is: lbs. My current Height
My other health and wellness goals are to:
My personal cleansing coach is:.
I Stace Zimmerman will always be your cleansing coach by default and as a backup, so call (home:
403-668-8515 or cell: 403-669-2876 or email me ssz at
top10reviews.info at anytime for
any reason and I will help you out! =)
I know that my cleansing coach will offer support,
encourage me, and provide advice on how to fulfill my goals. I will contact my
cleansing coach regularly to report my progress.
I will surround myself with positive and uplifting people
who will support & encourage me and not sabotage or discourage my efforts. My
personal support team includes:
My Health Commitment
commit to investing in my future health and in mine & my family’s future
happiness by immediately working to improve my health
and by being disciplined, focused and dedicated to my goals. I know that healthy and
permanent weight loss is a lifestyle change. Isagenix is not some quick-fix
band-aid solution to my health. Just like I didn’t get un-healthy or overweight
in days, I fully understand that my goals will take some time. But it will surely be
worth it! =) I will do whatever it takes to get to where I know I can be, should
be and will be in life. I take responsibility for my actions. I am totally
aware that I can do or be anything I want in my life, only if I choose to start
the journey, and stay the course, until I reach my destination, this is no race
it’s all about ultimately getting to be where you want, on your terms, pace and
Please digitally sign this form by typing in your full
name and today’s date in the boxes below.
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PRINT OFF THIS COMPLETED PAGE NOW!THEN HAND IT TO
A LOVED ONE(S) THAT WILL SUPPORT, ENCOURAGE, MOTIVATE YOU AND ALSO WILL PROMISE
TO KEEP YOU ACCOUNTABLE. DO IT NOW! YES NOW! DON’T LEAVE OUT THIS
VERY CRITICAL PART THINKING IT’S HOKEY OR YOU DON’T NEED TO DO IT, BECAUSE WHEN
I CALL YOU TO WORK OUT YOUR PERSONALIZED PROGRAM AND PLAN GUESS WHAT I WILL BE
ASKING? =) THAT’S RIGHT! THIS IS A VERY SERIOUS PART OF THE PROGRAM
TRUST ME! SO JUST DO IT NOW PLEASE THANK YOU! P.S YOU WILL BE THANKING ME
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