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Coaching Assessment
Hi Friend! Fill in the form below and it will help me pick the exact right health plan for you. After I get your form you can expect an email fro me to schedule a call to get you started! I cant wait to talk to help you reach all your goals!
Email address *
Contact Information
Name *
Your answer
Phone Number *
Your answer
Medical Questions
Do you have diabetes? (type I or II) *
Are you on any medications currently? *
Do you have high blood pressure?
Please list any medications you are currently taking.
Your answer
Your Goals
How would you describe your current state of health?
Your answer
How much weight would you like to lose? *
Tell me a time of your life when you were healthier (ie. in high school or college)
Your answer
What changed between then and now?
Your answer
What is your main motivation for losing weight?
Your answer
Your Sleep
How many hours of sleep do you get each night?
Your answer
What time do you typically go to bed at night and wake up in the morning?
Your answer
Do you feel rested when you wake up?
Your answer
Hydration
How much water would you say you drink a day? in ounces
Your answer
Do you consume any of the following at least 1 time a week?
Motion
On a scale of 1 to 10 how would you rate your energy level?
awful
wonderful
What types of physical activities do you engage in?
Your answer
Stress Levels
On a scale of 1 to 10 how would you describe your stress levels?
Non existent
I am constantly anxious
Can you identify some stressers in your life?
Your answer
Eating Habits
How many meals per day do you eat?
When do you eat your first meal?
Time
:
When do you eat your last meal?
Time
:
Do you snack between meals?
Can you identify any unhealthy eating habits?
Your answer
What is your body fat percentage? Use the picture bellow to estimate ( it does not need to be exact)
Estimated percentage *
Your answer
What is your activity level? *
How much do you currently weigh? *
Your answer
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