Wellness Consultation Follow-Up
Completed By:
*
Patient
Staff
Today's Date
*
-
Month
-
Day
Year
Email
*
example@example.com
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Weeks In Program?
*
Goal Progress
Primary Goal From Intake:
*
Progress Toward Goal:
*
On track
Some progress
No change
Worse
Biggest Win in Past 2 Weeks:
*
Nutrition Adherence
Adherence to Plan:
*
< 50%
50 - 69%
70 - 89%
90 - 100%
Has Your Nutrition Pattern Changed Since the Last Appointment?
*
Yes
No
If yes, please describe the adjustments:
Barriers? (top 1 or 2)
*
Cravings
Hunger
Time constraints
Eating out
Stress/emotional eating
Travel
Other
Physical Activity
Average Activity Level (past 2 weeks):
*
Sedentary
Light
Moderate
High
Exercise Frequency:
*
0 – 1 Days
2 – 3 Days
4 – 5 Days
6+ Days
Type of Exercise? (check all that apply)
*
Resistance
Cardio
HIIT
Sports
Mobility
Additional Comments:
Sleep & Recovery
Sleep Duration:
*
< 6 Hours
6 – 7 Hours
7 – 8 Hours
> 8 Hours
Sleep Quality:
*
Poor
Fair
Good
Excellent
Energy Level:
*
Low
Moderate
High
Symptoms / Health Changes
Since Last Visit (check all that apply):
*
Improved energy
Improved sleep
Fat loss noticed
Increased strength
GI issues
Fatigue
Mood changes
No changes
Other
Medications / Supplements Changes
Any Medication/Supplement Changes Since Last Visit?
*
Yes
No
If yes, please list below:
Readiness & Coaching Needs
Confidence For Next 2 Weeks:
*
High
Moderate
Low
Do You Want Changes To Your Plan?
*
No
Yes
If Yes, List Changes Below:
Barriers & Accountability
What Got In The Way Of Accomplishing Your Goals The Most? (1–2 Items):
*
Is There Anything Specific You Want To Focus On For This Appointment?:
*
Additional Notes:
Submit
Should be Empty: