Sleuth Form

Sleuth Form
SLEUTH FORM - PERSONAL HEALTH HISTORY

Please note that this form is OPTIONAL. The questions on this form were created by Trim Healthy Mama, not by Coach Jen. You do not have to share any information, medical or otherwise, if you don't wish to. Completing this form is an agreement that you understand that Coach Jen is not a physician, and any medical concerns you have must be taken to your doctor.
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Home Phone
Cell Phone
Email Address
example@example.com
Gender
Bust
Waist
Hips
L
R
Are you currently pregnant or nursing?
DO YOU HAVE NOW, OR HAVE YOU IN THE PAST:
Please choose all that apply:

A chronic illness or conditionElevated blood pressureMuscle, joint, or back painDiabetes or Metabolic SyndromeThyroid conditionPolycystic Ovarian SyndromeHormone imbalancesAdrenal fatigue
DO YOU EXPERIENCE ANY OF THESE SYMPTOMS:
Please choose all that apply:

Severe fatigue or loss of energyWeight gain, difficulty losing weightDepression and depressed moodJoint and muscle painHeadachesDry skin or brittle nailsBrittle hair, itchy scalp, or hair lossIrregular periods or PMS symptomsConstipation or diarrheaPuffiness in the face and/or extremitiesElevated levels of LDL (the "bad" cholesterol) and heightened risk of heart disease
Are you currently involved in a regular fitness program? If so, describe:
Are you involved in physical activities of daily living - walking, gardening, etc? If so, what type and how often?
What weight loss programs have you participated in over the last 10 years?
Would you characterize yourself by always trying a new diet or weight loss program?
What is your weight loss or gain history over the last 10 years?
How old were you when you started your first weight loss diet plan?
Long Term Goals: (Where do you want to be in 12 months?)
Goals: (Please keep in mind this is a lifestyle approach and not a race):
Weight Goal:
Clothing Size Goal:
Health Goal:
Additional Goals
What are the top 3 things you want/need from your Trim Healthy Coach?
1
2
3
Why did you seek out a Trim Healthy Coach?
What are your hindrances, if any, to losing weight implementing the Trim Healthy Mama Plan or falling short of your goals?
Which THM resources do you have access to?
Please choose all that apply:

Original Trim Healthy Mama BookTrim Healthy Plan BookTrim Healthy TableTrim Healthy FutureTrim Healthy Mama CookbookTrim Healthy IndulgenceTrim Healthy WisdomTHM Membership SiteTHM Official Facebook Groups
Do you feel your family and friends support your decision to improve your health?
Do you have a spouse family member or friend following the THM Plan? Please specify:
HOW ARE YOU BEST SUPPORTED?
Example: Gentle nudging, hard pushes, or somewhere in between:
Which type of mama do you relate to? (You can choose more than one)

Whole Grain Jane - You grind your own flour, eat mostly whole grains, your diet is high in fruit, dried fruits, and carbohydrates. (Example: banana-based smoothies)Drive Thru Sue - You are constantly on the go, frequent restaurant drive thru's, do not have time for a lot of cooking (or don't like to cook) and eat mostly a StandardRaw Green Colleen - You juice carrots, apples and the occasional greens. You sprout and dehydrate. Your diet is high in raw foods and vegan or vegetarian-basedFarm Fresh Tess - You eat mostly homemade and farm-raised meat and produce. Your diet also includes starchy carbohydrates like potatoes and pasta but always in whole food form. You are a meat and potatoes type family.Scared of Carbs Barb - You have been on and off low-carb diets for years and you are terrified of adding too many carbs into your diet, even though sometimes you find herself binging on them. Due to this low-carb state, your metabolism has slowed down and shedding weight has become much harder in recent years.Adrenal Splat Pat - You have adrenal issues, stalled weight loss, food sensitivities. Your fibromyalgia keeps you from exercising.Thyroid Mess Jess - You ate low-carb for a while, continue to put on weight, have low energy, dry skin, and dry hair.
Should be Empty:

Sleuth Form

SLEUTH FORM - PERSONAL HEALTH HISTORY

DO YOU HAVE NOW, OR HAVE YOU IN THE PAST:

DO YOU EXPERIENCE ANY OF THESE SYMPTOMS:

Which THM resources do you have access to?

HOW ARE YOU BEST SUPPORTED?