Jua Nutrition & Wellness
Weekly Check-In Form
Name
*
First Name
Last Name
Email
example@example.com
What’s the best thing that happened to you in the past 2 weeks due to being on this journey to improved health and wellness? What non scale victories did you notice in the past 2 weeks?
*
Reminder of how to win this journey:
Agreed
Disagree
Rate your accuracy in measuring how much you were eating and sticking to the Program the past 2 weeks
*
Please Select
Less than 5 (Poor) - did not measure most of my food at all
5-6 (Needs work) - eyeball estimated most of my food
7-8 (Good) - Measured ALMOST every single piece of food I put in my mouth using a scale and wrote it down
9-10 (Excellent) - Measured every single piece of food I put in my mouth using a scale to the last 0.1 gram and wrote it down
What would you like to focus on improving in the upcoming 2 weeks?
*
How can I be a better coach for you? What can I do to help you be more successful with your journey? If you were me helping you, what’s one thing you would do differently?
*
Are you taking supplements?
*
No
Yes
Type any other response (if needed)
Digestion, bowel movements & overall health in the past 2 weeks?
*
Please Select
Normal
Less than Normal (Constipation)
More than Normal (Diarrhea)
Sick
Any other notes, comments, questions or concerns?
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Submit
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