Fresh Start Health History Form

Fresh Start Health History Form Please fill out this form honestly and be specific as possible. I will be able to help you know more about you.

Name

Age

Height

Current Weight

Address

City

State

Zip

Gender

Email

example@example.com

Text/Phone Number

Do you know your blood type?

Do you currently have any heart issues?

Chest pain, lightheadedness, stroke history, fainting, etc.

Have you been diagnosed with high blood pressure?

Have you been diagnosed with High Cholesterol?

Do you have any diagnosed health conditions currently?

Do you have difficulty with physical exercise? If so, explain.

Are you pregnant or trying to get pregnant?

Do you have any breathing issues or lung problems?

Do you have any muscle, joint or back disorders or previous injury still affecting you?

Have you been diagnosed as a diabetic?

Do you have a thyroid disorder?

Do you currently smoke or use tobacco products?

Do you have a history of health problems in your family? If so, explain.

Do you have a history of health problems in your family? Explain

Are you on any current Medications/Prescriptions

Are you taking any supplements/ herbals?

What is your current Fitness Regimen? (time of day, activitiy, intensity)

Have you ever used Beachbody products before?

If so, it is required that you switch to Jen Thompson as your coach. Coach ID 447681. Email: jeneration_fitness@yahoo.com

Current Nutrition: List in detail what a typical day would consist of

Breakfast Time

Hour Minutes

AM/PM Option

Breakfast Items

Snack 1 Time

Hour Minutes

AM/PM Option

Snack 1 Items

Lunch Time

Hour Minutes

AM/PM Option

Lunch Items

Snack 2 Time

Hour Minutes

AM/PM Option

Snack Items

Dinner Time

Hour Minutes

AM/PM Option

Dinner Items

Evening Snack Time

Hour Minutes

AM/PM Option

Evening Snack Items

How much water do you normally drink in a day?

Do you drink calories

Do you drink alcohol?

Select any that relate to you:

Do you have a sweet tooth? Do you have salt cravings? Are you constantly hungry? Do you have no appetite?

What do you feel you need to work on?

Portions Emotional Control Meal Planning Reading Labels

Do you eat out a lot? If so, how often?

Do you pack your lunch? If so, how often?

What other diet plans have you tried in the past?

What is your main reason for wanting this Fresh Start Program?

What is the best time/day of week to do your initial consult with Coach Jen?

You will receive a message from Jen to schedule your 60 minute goal setting consultation!