Creating Optimal Health with Certified Independent Coach Nikki Reed
Please answer the below questions so I have a head start on helping you reach your goals! A few weeks with me (yes, just weeks) this will all change!
Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Where did you see this form?
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WHERE YOU ARE & WHERE DO YOU WANT TO BE
This section will give me a better idea of your current health and your health goals.
How would you describe your overall health? (Physical, mental, emotional)
Why do you want to lose weight and get healthy?
If you could change one thing about your life right now, then what would that be?
Are you being treated for any of the following conditions?
Gout
Type1 Diabetes
Type 2 Diabetes
Thyroid disease
High Blood pressure
High Cholesterol
Autoimmune condition
Heart disease
Other
Have you ever had weight loss surgery?
Are you...
Pregnant
Breast Feeding/ less than 6 mo old
Breast Feeding/less than 1 year old
Premenopause
Postmenopause
How much water do you drink per day?
I hate water, rarely any
Some 8-24oz
Average 24-64oz
High 64-120oz
How many meals do you eat per day?
Do you snack?
Yes, often
Yes, occasionally
Not really
No never
Only at night
How often do you exercise?
Rate your sleep (1=poor: 10=like a ROCK)
How many pounds are you away from you feeling more confident?
What weight loss programs have you tried previously and were you successful?
Rate your current level of commitment to health goals (1= not committed: 10=100% IN)
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