Your Health Journey - First Steps

Name

Email

example@example.com

Date

Today's Date

Address

City

State

Two Letter Abreviation

Zip Code

Phone Number

Area CodePhone Number

How did we connect?

If you were referred, name of person who referred you.

Preferred Method Of Contact

Awaken...Discover where you are and where you want to be!

Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)

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Describe where you would like to be in your Health...

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Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.)

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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)?

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Medical

Are You Pregnant

Are You Nursing

If yes, how old is your baby

Do you have the following

Do you have any food allergies, sensitivities or dietary restrictions?

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Are you taking any medications for:

List any medications or medical conditions that have dietary restrictions

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*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.

NOTE: It is recommended yu consult your healthcare provider prior to starting any weight loss progra, and during the course of your weight loss program. Check with your healthcare provider about any dietary restrictions with the medications and supplements you are currently taking. DO NOT USE any Optavia plan if you are pregnant or under the age of 13.

SLEEP

How many hours of sleep do you typically get?

What time do you typically go to bed?

What time do you typically wake up?

Sleep Quality on a scale of 1-10

Do you feel rested most days?

HYDRATION

How many ounces of water do you drink daily?

Do you drink Coffee?

Do you drink Soda?

Do you drink Tea?

Do you drink Alcohol?

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ENERGY & 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 (INCLUDING JOB DEMANDS)?

Are there things you can't do that you would like to be able to?

STRESS

How would you rate your stress level? (on a scale of 1-10)

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: DELIVERY, DRIVE THRU, TAKEOUT, ETC.?

Do you eat more fast food or sit down restaurants?

BMI CALCULATION BODY MASS INDEX

Current Weight

Goal Weight

Height

AGE / GENDER

Have you tried to lose weight before?

What has been most difficult about losing/maintaining weight in the past?

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SURROUNDINGS

How healthy would you rate your surroundings? (on a scale of 1-10)

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?

Do you learn best

Exploring Your Health Journey

WEIGHT LOSS

LEARNING HABITS