Michele Kubala Health Form

Let's Grow Young Together

We will achieve your goals and create your success story!
Full Name*

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Appointment: What days/times are you available for a quick 10-15 minute call?
Cell number
How did you hear about me or our programs? If a referral, please list their name.
On a scale of 1 to 10, how ready are you to make changes to improve your health?

1

2

3

4

5

6

7

8

9

10

1 is Just thinking about it., 10 is I'm READY!
Your WHY
What are you interested in acheiving?

Weight LossHave More EnergyHave Quality SleepLearn Daily Nutritional HabitsDecrease Joint PainOvercome Addictive EatingRetain My Muscle Mass
What is your MAIN MOTIVATION to lose weight or make changes in your daily habits?

Improve Overall Health for LongevityFit In ClothesPlay With Kids/GrandkidsDating/RelationshipsFeel Better About MyselfWant To Be More ActiveAvoid Taking MedicationsLower Blood Pressure or CholesterolStabilize Blood Sugar/Borderline DiabeticReduce Stress EatingTeach My Kids Healthy Eating Habits
Other MAIN MOTIVATION to get healthy.
What is your height and weight, right now?
How many pounds would you like to lose?
Medical
Do you have the following?

Diabetes - Type 1Diabetes - Type 2High Blood PressureGoutKidney DiseasePCOS
Are you taking any medications for:

DiabetesHigh Blood PressureHigh CholesterolThyroidBlood ThinnersOther
Please list the medication name and what it is treating.
List all multi-vitamins and probiotics you take?
Are you currently utilizing one of the following medical weight loss tools?

Bariatric SurgeryGLP1 ShotsPills
Or, are you considering utilizing one of the following medical weight loss tools?

Bariatric SurgeryGLP1 ShotsPills
Are you pregnant?

YesNoTrying
Are you nursing

YesNo
Sleep
On average, how many hours of sleep do you get?

4-55-67-89-10Other
Do you wake feeling rested?

YesNoSometimes
What time do you typically wake up?
What time do you typically go to bed?
Hydration
How many ounces of water do you drink each day?
Do you consume any other beverages?

CoffeeSodaTeaAlcoholJuice (Apple, Orange, Fruit, Other)
Motion
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
Do you currently exercise? Note: Exercise is not required.

YesNoSometimes
If you exercise...

WalkingCardioWeight LiftingExercise ClassesOther
Stress
How would you rate your stress level on a scale of 1-5?

1

2

3

4

5

1 is Low, 5 is High
What stressors do you have?

WorkFamilyHealthNoneOther
What do you do for work?
Do you love it?

YesNoSometimes
Food Allergies
Do you have any food allergies?
Do you have any of the following after eating?

BloatingConstipationsDiarrheaFlatulenceOther
Eating Habits
How many Main Meals do you eat, daily?

123More
How many Snacks do you eat, daily?

123More
How many days a week do you eat out or grab food on the go? (Coffee runs, fast food, sit down restaurants, take out, vending machines, etc.)

1-23-44-56-7Other
Weekly 'Out of House' Food Sources

Coffee ShopsFast FoodSit Down RestaurantsTake Out/Order InVending MachinesFamily/Friend HomesOther
Do you keep junk food in the house?

YesNoSometimes
In regards to highly addictive foods, do you consider yourself:

Highly SensitiveModerately SensitiveLow Sensitivity
Which foods are you addicted to?

Sugar/CarbsSalty Foods/SnacksFried FoodsUltra ProcessedOtherNone
Surroundings
How would you rate your surroundings?

1

2

3

4

5

1 is Supportive, 5 is Not Supportive
Do you have a supportive family and friends?

YesNoSometimes
Do you have healthy and active friends?

YesNoMix
Is there anyone in your life who would like to get healthy with you, or you'd like to inspire?
For learning purposes, do you prefer to read printed text or listen to audiobooks?

PrintAudio
Would you like to help your friends and/or family get healthy with you? If interested in learning what I teach, I'll send a 10 minute video?

YesNoMaybeNot right now
In 2019, my husband and I decided to try a clean nutrition-based weight loss plan for 30 days. Over five years later, we use the healthy habits we learned during our weight loss phase to maintain our healthy weight. Our plans work, when followed. I'll guide you and be your biggest cheerleader. It truly was the best decision we ever made for our health and lives.
Let's Grow Young Together.
Should be Empty:

Let's Grow Young Together

Your WHY

Medical

Sleep

Hydration

Motion

Stress

Food Allergies

Eating Habits

Surroundings