Getting to Know You <Confidential>
Please fill this form out as completely as possible so I can learn more about your current health and goals. Upon receipt of info, I'll be in touch and send you your 7-Day Free Trial of the Bangkok Health Coach App
First name
Last name *
Age *
Email *
Gender *
Health Goals
What are your major health, nutrition, or fitness goals? *
Select the biggest barriers to achieving the above goals?
What are 2 - 3 greatest strengths that will help you achieve these goals?
Please select the option that BEST describes how ready you are to make changes to your lifestyle to achieve these goals.
Clear selection
How important is this change to you? *
Extremely low importance
Extremely high importance
How confident are you that you will achieve this change? *
Extremely low confidence
Extremely high confidence
Medical Information
How would you describe your health?
Clear selection
Are you taking any prescription or over-the-counter medications or dietary herbs or supplements? If yes, please list the medications and state the reason for taking.
When was the last time you visited your physician?
Do I have permission to communicate with your physician? If yes, please state your physician’s name and contact phone number.
Do you have or has your doctor or another licensed healthcare professional told you that you have any of the following conditions? Check all that apply. *
Required
Past surgeries
Past injuries
Please describe any other health conditions you have, or for which you take medication.
Has anyone in your immediate family been diagnosed with any of the following? If yes, please describe.
Nutrition History
Have you ever followed at modified diet to manage a health condition? If yes, please describe.
Do you follow a specialized diet (low-carb, gluten-free, vegan, etc). If yes, please describe the diet and reasons for following:
Who purchases and prepares your food?
Physical Activity History
How physically active are you each week?
Clear selection
What types of exercise do you currently engaged in? Select all that applies. *
Required
Please list your favorite physical activities:
Weight History
What would you like to do regarding your weight?
Clear selection
What was is your current weight?
What is your height?
What was your lowest weight in the past 5 years?
What was your highest weight in the past 5 years?
Other
Is there any other information that you think I should know?
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