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
What are your major health, nutrition, or fitness goals?
Select the biggest barriers to achieving the above goals?
Lack of time
Not sure how to achieve them
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.
I do not believe I need to change
I would like to change, but don't think I can
I would like to intensify changes
I recently started to make changes ( in the past 6 months)
I've made changes but relapsed
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
How would you describe your health?
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.
Allergies. If so, please specify below.
Amenorrhea or absence of menstrual period
Chronic sinus condition
Gastroesophageal reflux disease (GERD)
High blood pressure/hypertension
Irritable bowel sydrome
Less than 3 months postpartum
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.
High blood pressure
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?
Not physically active
50 - 100 mins per week
101-150 mins per week
more than 150 mins per week
What types of exercise do you currently engaged in? Select all that applies.
Strength or resistance
Please list your favorite physical activities:
What would you like to do regarding your weight?
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?
Is there any other information that you think I should know?
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