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!
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Name
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First Name
Last Name
Phone Number
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Area Code
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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.
Right now, how much do you weigh? If you were like us, we didn't own a scale, before OPTAVIA.
Right now, how would you describe your overall health? Physical, mental, energy, self confidence...
Why do you want to lose weight? What do you think will be different in your life when you get to a healthy weight?
What do your dream health/weight goals look like?
What would you change about your life right now to make it better? We get some deep responses here, and I want you to know this is completely confidential
How old are you?
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
Any medcines? Thyroid, Anxiety, Depression or Off Label Diabetes Injections? Weight loss surgeries?
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?
We are confident in the program. Literally, you are the only variable to the programs success. It is simple, not always easy, but the things that matter in life are never easy. We know you can lose the weight you want with our help. Our lives were in shambles because of all the things we could NOT control. We decided to be excited that we could control one part of our lives. We are so excited to work with you! Are you ready?
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