Weekly Check-In Sample
Please submit completed check-in form within 24 hours completion of the week. I will respond within 24 hours of receipt.
Name *
Your answer
Date *
MM
/
DD
/
YYYY
Body Weight (lbs)
If using body weight as a weekly tracker, please take weight on same scale and same day of week, upon waking and prior to eating or drinking.
Your answer
Healthy Tasks
Check each day that the task was completed. If you need to add additional notes, please add them in the "Notes" section at the end of the form.
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Example: Include protein at 3 meals daily
Example: Plan 3 breakfast meals using template
Example: Macros: 1800 Calories 180gC/135gP/60gF
Please rate how easy or difficult it was adhering to this week's tasks *
1 = Very Easy Adhering to Task 5 = Very Difficult Adhering to Task
1 - Very Easy Adhering To Task
2
3
4
5 - Very Difficult Adhering to Task
Example: Include protein at 3 meals daily
Example: Planning 3 breakfast meals for week
Example: Macros: 1800 Calories 180gC/135gP/60gF
How was your appetite throughout the week? Were there any days you felt hungrier or more satisfied than others? *
Your answer
How was your sleep throughout the week? Were there any days you felt more rested than others? *
Your answer
How was your energy throughout the week? How did workouts feel and daily routine? Were there any days you felt more energized than others? *
Your answer
What went well this week? Positives & Successes? Any “praise yourself” moments? *
Your answer
Any limiting factors or obstacles that interfered with habits? Any successful ways you overcame the obstacle? *
Your answer
What changes are you noticing in the mirror? Changes in your energy level? Changes in sleep? Changes in mood? Changes in workouts? *
Your answer
Are you experiencing any negative symptoms with the dietary changes? *
Your answer
On a scale of 0-10, how would you rate your overall feeling of wellness and progress toward your goals right now? *
Not feeling improvement in wellness or progress toward goals
Seeing changes and feel I'm on track to meet my goals
Based on the wellness rating above, what one healthy task would increase your feeling of wellness and progress by .5 to 1 point on the rating scale? *
Your answer
Do you have any specific questions to be addressed during this check-in? Is there anything you want to focus on during the next check-in or receive more information about? *
Your answer
Notes
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Eclectic Wellness. Report Abuse