Your Health Journey - First Steps

Exploring Your Health Journey

with Doris Hauxwell
First Name*
Last Name*
Email*
example@example.com
Date*

MonthDayYear
Today's Date
Address*
City*
State*
Two Letter Abreviation
Zip Code*
Phone Number*
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Who referred you to our program?*
If you were referred, name of person who referred you.
Preferred Method Of Initial Contact

TextCallEmailZoom
Awaken...Discover where you are and where you want to be!
Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)*

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Describe where you would like to be in your Health...*

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Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.)*

0/330
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?*

0/330
On a scale of 1-10, how ready are you for change?
How much time per week are you willing to invest each week to learn and understand how to make your weight loss permanent?

Zero. I’m too busy10-15 minutes/week30 minutes/week60 minutes /week
Medical
Are You Pregnant

YesNo
Are You Nursing

YesNo
If yes, how old is your baby
Do you have the following

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

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Are you taking any medications for:

DiabetesHigh Blood PressureHigh CholesterolThyroid**Lithium*Coumadin (Warfarin)***
Are you taking other medications or have other medical conditions that could influence which program we choose?*

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*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 go to bed?
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 each day?
How much Coffee?
How much Soda?
How much Tea?
How much Alcohol?

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MOTION
How would you rate your energy level? (on a scale of 1-10)
How many times a week do you exercise?
What physical activities do you participate in?
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?
How much do you enjoy what you do?
Are there other stressors in your life?
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 a week do you eat out?
Where?
WEIGHT
Current Weight
Goal Weight
Height
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?*

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What do you consider your biggest obstacle to weight loss and long term health?
Have you utilized in the past or are you currently utilizing one of the following medically supported weight loss tools?

Bariatric surgeryGLP1 shotsPillsOther
In regards to highly addictive foods such as sugars/carbs, fried foods, and processed foods, do you consider yourself to have:

High SensitivityModerate SensitivityLow sensitivity
The program I coach is a habit transformation system that addresses lifestyle change in the form of nutritional and behavioral support. However, we have combination therapy options available to those who desire both medically supported weight loss in conjunction with lifestyle transformation. Do you desire to discuss if combination therapy would be a good fit for you?
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?
When it comes to your schedule, would you say any of the following:

I’m on the go! Practically live in my car and fast food is my go-toI’m equally on the go and at home. I have time to prepare healthy mealsI’m retired or I work from home. Fast food isn’t an issue.Other
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Exploring Your Health Journey