Health Can Be Simple Metabolic Evaluation
90% of Americans are experiencing metabolic dysfunction and don’t even know it! Metabolic Health is how efficiently your body uses food for energy, keeps blood sugar stable, supports muscle/hormones/brain health, and manages inflammation and fat storage. When these systems are out of balance, we experience metabolic dysfunction. Fill out the form below, or contact Amber & Jared Smithson at 801-356-3181.
Name
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Phone
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Format: (000) 000-0000.
Address
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Street Address
City
State / Province
Postal / Zip Code
Email
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Preferred Method of Contact
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Referred From?
3. Can you tell me about a time in your life when you were healthier? What has changed between then and now?
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Health goals / motivation behind them? (Weight, muscle, energy, etc.)
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What have you tried in the past?
4. Tell me about your health: Do you have any allergies or medical conditions that could influence which Program we choose?
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5a. Are you experiencing any of these metabolic markers?
Low energy or afternoon crashes
Weight gain (especially around the middle)
Difficulty losing weight despite trying
Poor sleep or waking up tired
Increased sugar or carb cravings
Brain fog or difficulty concentrating
Loss of muscle tone or strength
Elevated BS, cholest., lipids or BP
5b. Are you Nursing?
No
Yes
6. Are you taking any medication for:
Diabetes
High Blood Pressure
Lithium*
Thyroid
Coumadin (Warfarin)
Other
Are you experiencing any of these metabolic markers?
Low energy or afternoon crashes
Weight gain (especially around the middle)
Difficulty losing weight despite trying
Poor sleep or waking up tired
Increased sugar or carb cravings
Brain fog or difficulty concentrating
Loss of muscle tone or strength
Elevated BS, cholest., lipids or BP
Other
*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.
Tell me about your sleep:
What you drink daily / how much? (Water, Coffee, Soda, Alcohol, etc.)
Biggest struggles with food?
How often do you eat out?
Describe your exercise (Frequency, Intensity, Duration):
Rate your stress (scale of 1-10). Primary source of stress?
Current Height/Weight if known
Who would like to get healthy with you?
On a scale of 1-10, how much do you worry?
What area of your life tends to be the biggest stress for you?
What do you do for work?
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On a scale of 1-10, how much do you enjoy what you do?
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How many meals and snacks do you eat per day?
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When do you eat your first meal of the day?
How many times a week do you eat out? And where?
How many ounces of water do you drink per day?
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Do you drink other beverages? Coffee, soda, alcohol, tea, etc.
If so, how often and how much?
Age
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Height
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How much do you currently weigh?
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What would you consider to be a healthy weight for you?
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Have you tried to lose weight in the past?
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What has been difficult for you about losing and maintaining weight?
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On a scale of 1-10, how healthy would you rate your surroundings? (This includes: healthy friendships, supportive family, keep junk food in the house, etc
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Is there anyone in your life who would like to get healthy with you?
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Is there anything else you think I should know about your health?
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