Weight Loss Coaching Consult
Name
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Sex:
Male
Female
Height
Current Weight
Goal Weight
Current Diet: Describe your current eating habits. (meal frequency, snacking, fast food, organic foods etc...) Be Honest, I'm here to help, not to judge.
Steps: Do you track your steps daily? If so, what is your average? If you do not, do you have a smart watch, or a device you can use to track your steps?
Occupation: What do you do for work? Describe your daily activity level.
Exercise: What is your current exercise routine? (resistance training, cardio, walking/hiking) How many days per week?
Do you have a gym membership? Are you able to get a Gym Membership?
Do you have any medical conditions or family history of medical conditions I should be aware of?
Have you had a physical exam or "wellness checkup" with your doctor within the past 12 months?
List any medications or supplements you are currently taking.
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