Let's Talk About Your Health

Let's Talk About Your Health

Coach Kara Bwami
CONTACT INFO
Today's Date:

MonthDayYear
Date
Full Name:

First NameLast Name
Date of Birth:

MonthDayYear
Phone Number:
Format: (000) 000-0000.
E-mail:
example@example.com
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Method of Contact:
How did you hear about this program?
If you were referred please include the name of the person who referred you. I would like to thank them!
PAST & PRESENT
Describe where you are in your health now. (Weight, sleep, stress, energy, etc)
Describe where you would like to be in your health.
Please describe WHY you are interested in getting healthy. (What is your main motivation?... relationships, activities, how you feel, etc.)
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?
MEDICAL
Gender:
Are you pregnant?
Are you nursing?
If yes, how old is your baby?
Do you have the following? (Check all that apply):
Are there any food or other allergies that I should be aware of?
Are you taking any medications for:
*Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor.

**Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the client is on the Program and adjust medication.

***Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.
Are you taking other medications or have other medical conditions that could influence which program we choose?
SLEEP
How many hours of sleep do you typically get each night?
What time do you typically go to bed?
What time do you typically wake up?
How is your quality of sleep?
Do you wake up feeling rested?
HYDRATION
How much water do you drink each day?
How much coffee?
How much soda?
How much tea?
How much alcohol?
MOTION
How would you rate your energy level?

1

2

3

4

5

1 is Low Energy, 5 is High Energy
How many times a week do you exercise?
What physical activities do you participate in?
Are there things you can't do that you would like to be able to?
STRESS
How would you rate your stress level?

1

2

3

4

5

1 is Not Stressful, 5 is Very Stressful
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
EATING HABITS
How many meals per day do you eat?
When do you eat your first meal?
When do you eat your last meal?
Do you snack between meals?
What kind of snacks?
How many times a week do you eat out?
Where do you eat out?
ex: Fast Food, Dine-In Restaurants, Gas Stations, Coffee Shops etc.
WEIGHT
Current Weight:
Goal Weight:
Height:
Have you tried to lose weight before?
What has been the most difficult about losing/maintaining weight in the past?
SURROUNDINGS
How would you rate your surroundings?

1

2

3

4

5

1 is Not Good, 5 is The Best
Do you have healthy & active friends, supportive family, keep junk food in the house, etc.?
Is there anyone in your life who would like to get healthy with you?
Should be Empty: