Health Questionnaire
OPTAVIA Coaching with Erin White. Please complete this form as a starting point before we connect over the phone to discuss your heath goals. I will reach out within 24-48 hours of receiving your form. I look forward to connecting with you!
Name
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First Name
Last Name
Email Address
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Contact Phone Number
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-
Area Code
Phone Number
Age
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What do you do for a living?
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What would you like to achieve with your health (weight loss, improved sleep, better response to stress, etc.)?
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What's motivating you to make a change in your health (relationships, activities, how you feel, etc.)?
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What is preventing you from being your healthiest you (temptations, habits, barriers)?
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What kind of sleep do you get (8 hrs, wake up a lot, run on no sleep)?
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Tell me about your daily movement/exercise habits.
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At Optavia, we define health as the sweet spot between a healthy body, healthy mind, and healthy finances.
How would you rate your current "Healthy Body"? 10 being the healthiest your body has been and 1 being the most unhealthy.
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1
2
3
4
5
6
7
8
9
10
How would you rate your current "Healthy Mind"? 10 being the healthiest your mind and thoughts have been and 1 being the most unhealthy.
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1
2
3
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5
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9
10
How would you rate your current finances? 10 being the best your finances have ever been and 1 being the worst.
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1-2
2-3
3-4
4-5
5-6
6-7
7-8
8-9
9-10
If you close your eyes and imagine what the healthiest version of your self looks and feels like, what do you picture?
Do you have any health conditions that might effect which plan we choose? Choose all that apply:
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Diabetes Type 1
Diabetes Type 2
Heart Condition
Thyroid
Gout
High Blood Pressure
Cancer
Other
Are you taking medications for any of the following? Please list any other medications we may need to know about to choose the right program for you.
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Diabetes
High Blood Pressure
Lithium
Thyroid
Coumadin (Warfarin)
No Medications
Other
Do you have any food allergies?
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Are you pregnant or nursing?
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We will go over all that the program entails but do you have any burning questions that you want to make sure we address on our phone call?
When is the best time to reach you?
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Morning- 830am-11am
Mid-day- 11am-2pm
Afternoon- 2pm-5pm
Evening- 5pm-830pm
Anytime
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