Kelli Lewis's Health Assessment Let's Build Healthy Habits Together!
So happy you are here! Please answer the following questions to help give me an idea of where you are currently in your health journey.
Today's Date
-
Month
-
Day
Year
Birthdate
Ex: 1/1/1977
Pleae provide your full name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
How did you hear about this Health Program?
Referral
Facebook
Facebook Group
LinkedIn
Other
If someone referred you, please provide their name so I can THANK them:
First & Last Name
Let's Connect! What is your name on Facebook?
Have you tried other weight loss programs before?
Yes/No & Program Name
If YES, why do you think previous programs did not work for you?
How tall are you?
Example: 5'4"
Why are you wanting to lose weight right now?
Please be as open as possible!
How would you describe your current overall health? Physical, mental, emotional, energy, self confidence...
Please be open!
What will be different in your life when you get to a healthy weight?!
The possibilities are endless!
What would your dream health/weight goals look like?
What would you change about your life right now to make it better? (please remember, this is totally confidential. I used food/sugar to numb my emotions, so I get it. Share away...)
Are you being treated for any of the following?
Gout
Type 1 Diabetes
Type 2 Diabetes
Thyroid Disease
High Blood Pressure
High Cholesterol
Heart Complications
Other
If you selected other, please explain:
Are you:
Pregnant
Nursing
Pre Menopause
Post Menopause
Trying To Conceive
Not Applicable
Dietary Analysis: Please complete these questions in order for me to provide a proper dietary analysis. Based on the information provided I will be able to match a personalized plan designed just for you. Do you..
Rows
Always
Sometimes
Never
Drink Soda
Drink Alcohol
Cook Meals at Home
Eat Out Weekly
Have 6 Healthy Meals Daily
Drink 8 Glasses of Water Daily
Right now, how much do you weigh? If you're not sure, what is your best guess? Or what size pants do you wear currently?
Rate your quality of sleep?
Poor
Fair
Good
Excellent
Do you currently exercise? If so, how often, how much and what type...
How many pounds away are you from feeling confident?
Is there anyone in your life that you would love to get healthy WITH you?! Getting healthy with your spouse, bestie, coworker, etc can help your journey!
Type their name + your relationship
Best method of contact for you:
Call
Text
Email
Best day/time to reach you:
On a scale of 1-10, how committed are you to getting to Your health goals?
1 = least / 10 = committed
What else do you feel is important for you to share with me before we talk? I am 100% confident in this program and its ability to work for everyone no matter what your weight loss goal is. It's simple, not always easy, but the things that matter in life are never easy. I am so excited to work with you and I am honored to walk along side you in this health journey! I look forward to connecting with you soon! ~Coach Kelli
**BE SURE YOU CLICK THE SUBMIT BUTTON BELOW**
Submit
Should be Empty: