Ripple Effect Inc. Health Assessment

Health Consult Form

“Even the smallest changes in our daily routine can create incredible ripple effects that expand our vision of what is POSSIBLE”
LETS DO THIS! 👊🏻

Please complete this form to schedule a free health assessment
Name

First NameLast Name
Birthday (DOB)
Contact Number
Email
example@example.com
Best day/time to contact you?

DayTime
Where did you hear about me?

Other
Do you have a coach?
If so, what is your previous coaches name?
Let's talk about your goals!
I want to improve in the following areas:

Other
What is your why? Is there an event you are working towards? Fit into your clothes better? Want to clean up your lifestyle? Want to lower your blood work? Get off medications? Do you want to FEEL better? Run around with your kids? Be specific!
Medical Conditions
Do you have any medical conditions?
If yes, please specify: Diabetes (Type 1 or 2) PCOS, Kidney Disease, Gout, Thyroid Issues, High Blood Pressure, High Cholesterol
Have you utilized in the past or are you currently utilizing one of the following medically supported weight loss tools?
In regards to highly addictive foods such as sugars/carbs, fried foods, and processed foods, do you consider yourself:
The program I coach is a Habit Transformation System that addresses lifestyle change in the form of nutritional and behavioral support. However, we have combination therapy options available to those who desire both medically supported weight loss in conjunction with lifestyle transformation. Do you desire to discuss if combination therapy would be a good fit for you?
Are you taking any medications or vitamins? If so, please specify
Do you have any food allergies or sensitivities? If so, please list.
Are you currently pregnant or breastfeeding ?
Are you currently working out?
If so, how many days a week?
What physical exercise/activity do you participate in?
How would you rate your stress level on a scale 1–10?
What do you do for work?
Dietary Analysis:

Please complete these question in order for me to provide a proper dietary analysis. Based on the information provided I will be able to match a personalized plan designed just for you.

Do you..............

Rows	Always	Sometimes	Never
Eat out
Drink 8 Glasses of Water
Eat 3 meals a day
Drink alcohol
Drink soda

What do you feel is your biggest downfall? (Portion control, sweets, salty, alcohol etc.)
How old are you?
How tall are you?
How much do you weigh? (If you’re not sure, a round about)
In a PERFECT world, if you could not fail, how much weight would you want to lose?
Is there anything else you would like to tell me that would help me get you to your goal, and help you be successful?
Who is that special someone in your life that you would like to get healthy with you?
(***Incentive for more than one person or a friend doing it together!)
Thank you so much. Looking forward to speaking with you!! CLICK THE LINK BELOW TO SUBMIT & I WILL BE IN TOUCH WITHIN A FEW HRS
Should be Empty:

Health Consult Form

LETS DO THIS! 👊🏻

Dietary Analysis: