Your Health Journey

Exploring Your Health Journey

With Health Coach Doug Redig
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Phone
Email
example@example.com
Who referred you to our program?
Preferred Method of Contact

TextCallEmail
AWAKEN…

Discover where you are and where you want to be!
Describe where you are in your health right 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, Energy, longevity 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)?*
Are there other stressors in your life?
MEDICAL
Are you Nursing?

YesNoYesNo If yes, how old is your baby?
If yes, how old is your baby?
Are you taking any medications for

DiabetesHigh Blood PressureHigh CholesterolCoumadin (Warfarin)***Thyroid**Lithium*
Are you taking other medications or have other medical conditions that could influence which program we choose?*
*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.
SLEEP
How many hours of sleep do you typically get?
How is your quality of sleep?
Do you feel 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? (On a scale of 1-10)
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? (1-10)
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
Eating Habbits
How many meals do you eat each day?
When do you eat your first meal?
When do you eat your last meal?
Do you snack?
What kind of snacks?
How many times a week do you eat out?
Where?
Weight
Current weight?
Goal weight?
Height?
Have you tried to lose weight before?
DAILY ROUTINE & HABITS
What has been most difficult about losing/maintaining weight in the past?
How healthy would you rate your surroundings?
(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:

Exploring Your Health Journey

AWAKEN…

MEDICAL

SLEEP

Hydration

Motion

Stress

Eating Habbits

Weight

DAILY ROUTINE & HABITS