Katie Cotton Health Assessment

My Current Health Reality

So happy that you are here. Complete this form so I can learn more about you and your health goals! Looking forward to connecting. ~ Coach Katie
Name

First NameLast Name
Today's Date

MonthDayYear
Date
Contact Number
Email
example@example.com
Date of Birth

MonthDayYear
Date
How did you hear about our program??
If you were referred by a friend, please name the person who referred you.
Let's Talk About Your Goals!
I want to improve in the following areas:

Other
What is your "Why?" for getting motivated to get healthy? (Is there an event you are working towards? Fit into your clothes better? Want to clean up your lifestyle?) Be specific!
Are you currently working out?
Sleep Patterns
Do you get good quality sleep (7 or more hours) ?
Do you wake feeling rested?
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..............

Is there anyone in your life who would like to get healthy with you? Having someone else to lean on can be helpful!
Are you ready to commit to yourself and get healthy?
Thank you so much for taking the time to fill out this form. It is the first step to getting healthy! I will connect with you soon so we can chat and see which program is the best fit for you.

I look forward to meeting you! ~ Coach Katie
Katie Cotton, OPTAvia Health Coach
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My Current Health Reality