Coaching with Kim Smith
Independant Certified Optavia Heath Coach
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Take a few minutes to figure out where you are in your health journey and where you want to be. Then together, we'll get you on the path to success.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about our program?
*
Describe where you are in your health right now (weight, sleep, energy, stress, etc.).
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Describe the areas of your health you would like to improve (weight, sleep, energy, stress, etc.).
How much weight would you like to lose?
What is your reason for wanting to make a change now?
On a scale of 1-10, how would you rate your motivation for reaching your goal?
Are you being treated for any of the following medical conditions? (Please check all that apply.)
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Pre-Diabetic
Type 1 Diabetes
Type 2 Diabetes
Gout
High Blood Pressure
Tyroid
IBS
High Cholesterol
Other
What medications are you taking?
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Any food allergies or aversions (anything you hate)?
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How many times a week do you typically eat out?
Do you drink alcohol?
If so, how many days per week do you drink alcohol?
Is there anyone else in your life who would like to get healthy with you?
Is there anything else you would like to share with me that you feel would be helpful?
Submit
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