My Current Health Reality

My Current Health Reality

So happy you are here! Please answer these questions before we chat. 😀
Name*

First NameLast Name
Preferred Email*
example@example.com
Date*

MonthDayYear
Today's Date
Address*
City*
State*
Two Letter Abreviation
Zip Code*
Phone Number*
Date of Birth

MonthDayYear
Date
How did you hear about our program?
If you were referred, name of person who referred you.
Preferred Method Of Contact*

TextCallEmail
Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)*

0/330
Describe where you would like to be in your Health...*

0/330
Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.)*

0/330
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)?*

0/330
Medical
Are You Pregnant

YesNoNot applicable
Are You Nursing

YesNoNot applicable
If yes, how old is your baby
Are there any food or other allergies that I should be aware of?

0/160
*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.
SLEEP
How many hours of sleep do you typically get?*
What time do you typically go to bed?
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 daily?*
How much Coffee daily?
How much Soda daily?
How much Tea daily?
Do you drink Alcohol?
If yes, how often and what type of alcohol?
MOTION
How would you rate your energy level? (on a scale of 1-10)*
How many times a week do you exercise?*
What physical activities do you participate in?
Are there things you can't do that you would like to be able to?*
STRESS
How would you rate your stress level? (on a scale of 1-10)
What do you do for work?
How much do you enjoy what you do?
EATING 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?
How much do you spend daily eating out?*
WEIGHT
Current Weight *
Goal Weight *
Height*
On a scale of 1-10 (10 meaning ready to go!), how motivated are you to start working on your health goals?*
What has been most difficult about losing/maintaining weight in the past?*

0/200
SURROUNDINGS
How healthy would you rate your surroundings? (on a scale of 1-10)*
Do you have healthy & active friends, supportive family, keep junk food in the house, etc?
Is there anyone in your life who would like to get healthy with you? If so who?
Is there anything else you would like to share with me?
Thank you for completing my questions. Please text me @ 225-933-8597 and let me know you have submitted your answers so we can set up a time to discuss which program is right for you. Your first step toward better health is complete! So excited to be your coach! 💖~ Stephanie Alexander Brooks
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My Current Health Reality

Thank you for completing my questions. Please text me @ 225-933-8597 and let me know you have submitted your answers so we can set up a time to discuss which program is right for you. Your first step toward better health is complete! So excited to be your coach! 💖~ Stephanie Alexander Brooks