Megan Gilliland - Health Assessment

Thank you so much for reaching out!

This is your starting point. Time to create your future!
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CURRENT HEALTH ASSESSMENT

This section will give me a better idea of your currently in your health.
What is your current age?
How tall are you?
How much do you currently weigh?
Marital Status
Do any of the following apply to you? (select all that apply)

Other
Are you pregnant?
Are you nursing?
SITUATIONAL HEALTH: Are there situations or factors making your life difficult right now that could hinder you from prioritizing your health? (What feels out of control right now?)
How many other weight loss programs have you tried? Lord knows we tried too many! If so, what have you tried?
STRESS: Describe your most common sources of worry or stress. How do they affect your daily life? 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. I knew my work life home life balance and finances were in trouble before I started losing weight. Both were big reasons I ate and drank. I get it!
HEALTH GOALS

This section will give me a better idea of what you are looking to accomplish with your health.
What would you like to accomplish with your health (select all that apply)?
Why do you want to lose weight? What do you think will be different in your life when you get to a healthy weight?
COMMITMENT
TIMEFRAME: By when are you hoping to see significant changes toward your health goals?
COMMITMENT LEVEL: On a scale of 1-10, how committed are you to making lasting changes in your health?

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1 is NOT SO SURE, 10 is FULL STEAM AHEAD
SLEEP HABITS
How many hours of sleep do you get on average each night?
How would you rate the quality of your sleep on a scale of 1 to 10? 10 being the best sleep of your life!

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1 is HORRIBLE, 10 is EXCELLENT
FOOD AND SPENDING HABITS
On average, how much do you spend on food and beverage each day?
What does a typical day of eating look like for you? (This includes beverages - Starbucks, alcohol, anything that goes in your mouth. Please include when you have your first meal of the day and how many times you eat throughout the day.)
HYDRATION
How much water do you drink daily?
How much alcohol/soda/sweet tea weekly or monthly do you consume? What are your drinks of choice?
ENERGY LEVELS
On a scale of 1 to 10, how would you rate your average energy level throughout the day?

NOT GOOD GREAT
EXERCISE AND MOVEMENT

If you aren't currently moving your body....don't freak out!
Do you exercise?
Describe the type and intensity of the healthy motion you typically do. (If you don't currently move your body, that's OK! If you are currently incorporating healthy motion into your week, please let me know how many times per week.)
SUPPORT SYSTEMS
Who supports you in your health journey? How do they do so? If you do NOT feel supported in making healthy choices, please let me know that, too.
Name 5 people (first name only) that are in your life that need to make health changes.
If this program is a good fit for you, is there anyone you'd like to join you? List names here of the loved ones you would want to support getting healthy.
VISION: If you could describe your optimal health in one sentence, what would it be? Why is achieving this vision important to you? Dive deep and think about how it would change your daily life and long-term future.
How do you motivate or inspire those around you?
MINDSET

This section will give me a better idea of how you think, behave and feel.
EMOTIONAL CHECK-IN: On a scale of 1 to 10, how would you rate your overall emotional well-being right now?

Not Good Great
PERSONAL REFLECTION: Right now, how would you describe your overall health? Physical, mental, energy, self confidence...
Describe a time when you faced a challenge and how you addressed it.
How have you supported someone in the past to achieve their goals?
Would you say you are more outgoing or reserved?
Would you say you are more task-oriented or people-oriented?
What is the hardest part of being you right now?
WORK LIFE
What do you do for work?
On a scale of 1-10, how much do you enjoy what you do?

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1 is I HATE IT, 10 is VERY HAPPY
FINAL REFLECTION: Imagine it's a year from now, and you've made significant progress in your health journey. What do you think made the biggest difference?
Additional comments you want me to know:
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Thank you so much for reaching out!

CURRENT HEALTH ASSESSMENT

HEALTH GOALS

COMMITMENT

SLEEP HABITS

FOOD AND SPENDING HABITS

HYDRATION

ENERGY LEVELS

EXERCISE AND MOVEMENT

SUPPORT SYSTEMS

MINDSET

WORK LIFE