JOURNEY TO YOUR HEALTHIEST YOU!
HEALTH GOALS AND WELLNESS
First Steps to a Healthier You!!!
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Best Phone Number
-
Area Code
Phone Number
Email
example@example.com
Describe where you are in your Health now...(Weight, sleep, stress, energy, etc)
Describe where you would like to be in your Health...
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 remembered feeling your best in your health of being at our ideal weight or size (if that's part of your goal)?
Are You Pregnant
Yes
No
Are You Nursing
Yes
No
Do you have any of the following?
Rows
Yes
No
Diabetes Type 1
Diabetes Type 2
High Blood Pressure
Gout
Thyroid Disease
Sleep Apnea
High Cholesterol
Are you you taking any medications? If so please list them by name.
How would you rate your energy level? (on a scale 1-10)
How many times a week do you exercise?
List the workout or activities that you really enjoy.
Are there things you can't do that you would like to be able to do?
Yes
No
How would you rate your stress level? (on a scale 1-10)
Do you sit or walk more at work?
Do you enjoy your job?
Yes
No
How many meals per a day do you eat?
When do you eat your first meal?
When do you eat your last meal?
Do you snack in between meals?
What kind of snacks do you like?
How many times a week do you eat out?
Do you pick fast food or sit down restaurants more?
What beverages do you drink on a daily/weekly basis?
Water
Soda
Coffee
Alcohol
Sweet Tea
Are you an emotional eater?
Yes
No
What is your comfort food? (When your stress, bored, lonely, unhappy, and dealing with anxiety)
Current Weight
You can see where you are currently at and determine your goal.
Goal Weight
Height
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?
What is something you would like me to know about you?
Do you know anyone that is struggling with their weight and would be interested in this program?
Yes
No
Who referred you to this program?
Thank you for your time! I am excited that you are taking the steps of getting healthy.
Submit
Should be Empty: