Katie Webb Health Assessment

Just wait... a few weeks with me, yes, just weeks and this will all change..
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
Right now, how would you describe your overall health? Physical, mental, energy, self confidence…*

0/330
Please describe WHY you are interested in getting healthy and losing weight? What do you think will be different in your life when you get to a healthy weight? *

0/330
Medical
Are You Pregnant

YesNoNot applicable
Are You Nursing

YesNoNot applicable
If yes, how old is your baby
Do you have any of the following medical diagnoses*

Diabetes - Type 1Diabetes - Type 2High Blood PressureGoutPre-diabeticnone of these
Are there any food or other allergies that I should be aware of?

0/160
Are you taking any medications for:*

DiabetesHigh Blood PressureHigh CholesterolThyroid**Lithium*Coumadin (Warfarin)none of these
*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 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?*
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 and how many hours per week do you 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 per week do you eat out?*
What restaurants do you typically frequent?
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?*
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?
I am 100% confident in the program and its ability to work for everyone. Literally, you are the only variable to the programs success. It’s simple, not always easy, but the things that matter in life are never easy. I know you can lose the weight you want with my help, but with you being the only variable, if you fail, its your fault, if you succeed its also your fault. How does that make you feel? Scared? Good! I was too. BUT, my life was in shambles because of all the things I could NOT control. I decided to be excited that I could control one part of my life. How do you feel now? I am so excited to work with you! Thank you for completing these questions. This truly helps to paint a picture of where you are currently in your health. Please text me at 714-319-1521 when you submit the form. -Katie Webb
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Just wait... a few weeks with me, yes, just weeks and this will all change..