Let’s change your life!

Let’s change your life!

Helping YOU move from STUCK to UNSTUCK in your life!
Name

First NameLast Name
Email
example@example.com
Who did you hear about this program from? OR who is your current coach?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birth Date

MonthDayYear
Date
How did you hear about our program?
If you were referred, name of the person who referred you.
GOALS
Describe where you are with your Health now... (weight, sleep, stress, energy, ect)
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, how you feel, ect.)
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)?
MEDICAL
Sex
If Female are you pregnant?
Are you nursing?
If yes, how old is your baby?
Do you have any food allergies or sensitivities? If yes, please describe.
Do you currently take any medication or are you diagnosed with any of the following?

Other
¹Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor²Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication.³Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication
Do you have any additional health issues or are you on any other medications other than the above that I need to be aware of? If yes, please describe:
SLEEP
How many hours of sleep do you usually get?
What time do you typically go to sleep?
What time do you typically wake up?
How is your quality of sleep?
Do you wake up feeling rested?
HYDRATION
How much water do you drink each day?
How much coffee?
How much soda?
How much Tea?
How much alcohol?
MOVEMENT
How would you rate your energy level? (1-10)
How many times a week do you exercise? (You can say zero)
What kind of physical activity do you participate in?
Are there things you can't do that you would like to be able to do?
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?
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?
Where?
WEIGHT
Current weight
Goal weight
Height
SURROUNDINGS
How healthy would you rate your surroundings? (1-10)
Do you have healthy active friends, supportive family, keep junk food in the house, ect?
Is there anyone in your life who would like to get healthy with you?
Their First Name
Their Last Name

Thank you for taking the time to complete this form and share some insight into your health and life. Please hit submit and I'll follow up with you shortly!

In the meantime, I can be reached at 269-719-5889
or hmromine@gmail.com

Have an awesome day and I can't wait to talk about how we can CHANGE YOUR LIFE!!

Your Health Coach,

Heidi Romine

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Let’s change your life!

GOALS

MEDICAL

SLEEP

HYDRATION

MOVEMENT

STRESS

HABITS

WEIGHT

SURROUNDINGS