Health Evaluation
Eric Stofman, Certified OPTAVIA Coach
Full Name
*
First Name
Last Name
Address
Street Address
Address 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
How did you hear about us?
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Health goals / motivation behind them? (Weight, muscle, energy, etc.)
What have you tried in the past?
Health conditions you take meds for / food allergies (Weight loss meds, Diabetes, High Blood Pressure, Thyroid, Cholesterol)?
Tell me about your sleep:
What you drink daily / how much? (Water, Coffee, Soda, Alcohol, etc.)
Biggest struggles with food?
How often do you eat out?
Describe your exercise (Frequency, Intensity, Duration):
Rate your stress (scale of 1-10). Primary source of stress?
Height/Weight? What's a healthy weight for you?
Who would like to get healthy with you?
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