Small Hinges Deep Dive Intake

Take this survey to find out what small hinges are best for you to try

NEW PARTICIPANTS: I'll need your name, address, email & phone #, PLUS, an honest account of your goals, what motivates you, what you are willing and ready to change, and any medical conditions, medications and allergies you might have. Let's get started...

Question Title

* 1. Contact Info

Name *

Company

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number *

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* 2. Health & Wellness

Age

Height

Weight

BMI (or body fat %)

Any known medical conditions/issues?

Do you know if you have either or both of the MTHFR gene mutations? If yes, which ones?

Medications (including supplements)

Allergies and igG food sensitivities?

Have you taken an IgG food sensitivity test? (Pinnertest, Everylwell, etc.)

Blood type

Injuries & Surgeries (date)

Major life changes (date)

Family structure (married? children? divorced?)

Mental health concerns/issues

How much sleep per night? On average.

Alcohol or drug use, what and how often?

Programs/diets tried previously (please add results)

Exercise (what and how often)

Hobbies (what and how often)

Obligations to others (kids, work, volunteer)

Fitness/health tracker (Whoop, FitBit, etc.?)

How often do you have a bowel movement? Is it normally soft/hard/loose?

Do you drink coffee, if so how much?

How much water do you drink per day?

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* 3. Weekday schedule (wake, eat, work, exercise, sleep)

Wake up

Time

AM/PM

Breakfast

Time

AM/PM

Snack

Time

AM/PM

Lunch

Time

AM/PM

Dinner

Time

AM/PM

Desert

Time

AM/PM

Exercise

Time

AM/PM

Get in bed

Time

AM/PM

Fall asleep

Time

AM/PM

Sleep interruptions

Time

AM/PM

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* 4. WeekEND schedule (wake, eat, work, exercise, sleep)

Wake up

Time

AM/PM

Breakfast

Time

AM/PM

Snack

Time

AM/PM

Lunch

Time

AM/PM

Dinner

Time

AM/PM

Desert

Time

AM/PM

Exercise

Time

AM/PM

Get in bed

Time

AM/PM

Fall asleep

Time

AM/PM

Sleep interruptions

Time

AM/PM

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* 5. Goals of Small Hinges Changes

	100% YES	Would be a nice added benefit	Not sure I can have that	Need more info	Not applicable
Weight loss	Weight loss 100% YES	Weight loss Would be a nice added benefit	Weight loss Not sure I can have that	Weight loss Need more info	Weight loss Not applicable
Reduce pain	Reduce pain 100% YES	Reduce pain Would be a nice added benefit	Reduce pain Not sure I can have that	Reduce pain Need more info	Reduce pain Not applicable
Heal disease	Heal disease 100% YES	Heal disease Would be a nice added benefit	Heal disease Not sure I can have that	Heal disease Need more info	Heal disease Not applicable
More energy	More energy 100% YES	More energy Would be a nice added benefit	More energy Not sure I can have that	More energy Need more info	More energy Not applicable
Fertility	Fertility 100% YES	Fertility Would be a nice added benefit	Fertility Not sure I can have that	Fertility Need more info	Fertility Not applicable
Balance hormones	Balance hormones 100% YES	Balance hormones Would be a nice added benefit	Balance hormones Not sure I can have that	Balance hormones Need more info	Balance hormones Not applicable
Happier / less stress	Happier / less stress 100% YES	Happier / less stress Would be a nice added benefit	Happier / less stress Not sure I can have that	Happier / less stress Need more info	Happier / less stress Not applicable
Hair/Skin/Nails	Hair/Skin/Nails 100% YES	Hair/Skin/Nails Would be a nice added benefit	Hair/Skin/Nails Not sure I can have that	Hair/Skin/Nails Need more info	Hair/Skin/Nails Not applicable
Confidence	Confidence 100% YES	Confidence Would be a nice added benefit	Confidence Not sure I can have that	Confidence Need more info	Confidence Not applicable
Better relationships	Better relationships 100% YES	Better relationships Would be a nice added benefit	Better relationships Not sure I can have that	Better relationships Need more info	Better relationships Not applicable
Financial security	Financial security 100% YES	Financial security Would be a nice added benefit	Financial security Not sure I can have that	Financial security Need more info	Financial security Not applicable
Boost immunity	Boost immunity 100% YES	Boost immunity Would be a nice added benefit	Boost immunity Not sure I can have that	Boost immunity Need more info	Boost immunity Not applicable
Mental clarity	Mental clarity 100% YES	Mental clarity Would be a nice added benefit	Mental clarity Not sure I can have that	Mental clarity Need more info	Mental clarity Not applicable
Knowledge of what works for me	Knowledge of what works for me 100% YES	Knowledge of what works for me Would be a nice added benefit	Knowledge of what works for me Not sure I can have that	Knowledge of what works for me Need more info	Knowledge of what works for me Not applicable

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* 6. Deep Dive into Goals & Planning (answer "NA" for anything that is Not Applicable to you

What do you feel you NEED to change?

What do you feel you CANNOT change?

What do you feel you CAN change easily?

What results are you looking to achieve by working with Small Hinges?

What results are you looking to MAINTAIN long term?

How quickly do you NEED to see results?

How quickly do you WANT to start?

What is blocking you from starting?

What is your current feeling about starting? (scared, confused, excited, ready, lazy, frustrated, unsure, etc.)

Do you feel that you NEED 1-on-1 support from a coach?

Would you be willing to participate in a small group for support - IF your identity is known?

Would you be willing to participate in a small group for support - IF you are anonymous?

Do you like to cook?

Do you live with someone who likes to cook?

Do you like to exercise?

Do you have a dog?

Do you live in a house, apartment, or townhouse/multi-family?

What do you do for work?

Do you feel financially strapped/stressed?

Does your financial situation impact the type of food, beverages, supplements you consume? Does it impact the type of exercise you do, skincare you use, mode of transportation, area you live? (be specific)

Do you commute to work? Or work from home?

If you have children, how old are they? (put "N/A" if you do not have children)

Do you feel you can be fully self-expressed in your relationships?

Do you feel you have love and support from your family and friends?

Do you feel you have support from your colleagues and superiors?

How much time do you spend watching TV and on your devices PER DAY?

Write a statement that represents how you feel about yourself RIGHT NOW? I am...

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* 7. Do you consider yourself any or some of these (check ALL that apply):

outgoing

grateful

happy

loved

alone

lonely

sad

positive

depressed

stressed

unsure

scared

stuck

tired

sick

ugly

beautiful

safe

free

reserved

loner

shy

dreamer

pragmatist

truth seeker

smart

funny

fun

energetic

lazy

unhealthy

work in progress

ready for change

can't change

supported

adored

judged

lost

seeking help

helping others

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* 8. What I LOVE to Eat and Drink? (list EVERYTHING you LOVE)

Breakfast, lunch, dinner, snacks, desserts, beverages...

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* 9. What I CANNOT Eat & Drink... (list EVERYTHING, and why - don't enjoy vs. allergy vs. aversion vs. bad reaction)

Breakfast, lunch, dinner, snacks, desserts, beverages...

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* 10. Which Small Hinge Changes Would You LIKE to Try?

	Ready right now	Will try next/soon	Need more info	Maybe	Never
Diet	Diet Ready right now	Diet Will try next/soon	Diet Need more info	Diet Maybe	Diet Never
Beverages	Beverages Ready right now	Beverages Will try next/soon	Beverages Need more info	Beverages Maybe	Beverages Never
Exercise	Exercise Ready right now	Exercise Will try next/soon	Exercise Need more info	Exercise Maybe	Exercise Never
Sleep	Sleep Ready right now	Sleep Will try next/soon	Sleep Need more info	Sleep Maybe	Sleep Never
Mindset	Mindset Ready right now	Mindset Will try next/soon	Mindset Need more info	Mindset Maybe	Mindset Never
Environment	Environment Ready right now	Environment Will try next/soon	Environment Need more info	Environment Maybe	Environment Never
Schedule	Schedule Ready right now	Schedule Will try next/soon	Schedule Need more info	Schedule Maybe	Schedule Never
Relationships	Relationships Ready right now	Relationships Will try next/soon	Relationships Need more info	Relationships Maybe	Relationships Never
Extra Curriculars / Hobbies	Extra Curriculars / Hobbies Ready right now	Extra Curriculars / Hobbies Will try next/soon	Extra Curriculars / Hobbies Need more info	Extra Curriculars / Hobbies Maybe	Extra Curriculars / Hobbies Never
Financial	Financial Ready right now	Financial Will try next/soon	Financial Need more info	Financial Maybe	Financial Never
Job/Career	Job/Career Ready right now	Job/Career Will try next/soon	Job/Career Need more info	Job/Career Maybe	Job/Career Never
Volunteer	Volunteer Ready right now	Volunteer Will try next/soon	Volunteer Need more info	Volunteer Maybe	Volunteer Never

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* 11. If you are ready to get started, what would be best for you?

1-on-1 Coaching w/ Lindsay $250 per session or $400 per month for 2 sessions per month ($100 savings)

Wellness Insiders Group $49.99 p/mo. or $499.99 per year ($100 savings)

FIT 176 TEST $385)+ Initial Consult & Planning - 2 hours $400 (no ongoing coaching) = $600 ($185 savings)

Not ready to get started

Need more info

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* 12. By filling out this form, I agree to participate in a program or consultation with one of Small Hinges LLC’s team of experts. I understand that Small Hinges LLC is not a medical institution, and will follow any received advice, recipes or guidance with my health, allergies, medication, injuries, and wellbeing in mind. I will not hold Small Hinges LLC or any participating "experts" or employees of the company liable for any recipes shared, advice or supplements recommended, that negatively impact or hurt me and/or my family. No refunds, discount no exchanges shall be given for any reason. All of the information I've shared in this survey is true and current to the best of my knowledge. I agree to share my data, to experts, research organizations, and other partners of Small Hinges LLC. I promise not to copy, share or give access to Small Hinges' documents, programs, plans, workshops, events, etc. I am solely responsible for the result of implementing the protocol from any programs, consultations, workshops, etc., and any ongoing plans from Small Hinges LLC in my own life. Small Hinges LLC does not make any representations, promises or guaranteed outcomes from their app, programs, challenges, consultation, and will not be held liable for any reason.