Contact Information
Name
*
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
Age
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Gender
*
Male
Female
Time Zone
Back
Next
Body Measurements
Current Weight
Height
Current BMI
Measurements
Neck
Bust
Waist
Hips
Thighs L
Thighs R
Calf R
Calf L
Ankle R
Ankle L
Forearm L
Forearm R
Current shirt size:
Current pant size:
Back
Next
Work Info
Click all that apply
Full time
Part time
Self-employed
Work from home
Retired
Volunteer
Household manager
Care giver to disabled person
Care giver for elderly family member
I travel for my job
My job is physically demanding
My job is dangerous
My job is psychologically stressful
My job has a steady and regular schedule
My job is odd or overnight hours
Back
Next
Health History
Are you currently pregnant or nursing?
*
Pregnant
Nursing
Pregnant and nursing
Neither
Are you currently taking any medications or supplements? List them along with the dosage.
Do you have now, or have you had in the past (check all that apply):
A chronic illness or condition
Elevated blood pressure
Muscle, joint, or back pain
Diabetes or metabolic syndrome
Thyroid condition
Polycystic Ovarian Syndrome
Hormone imbalance
Adrenal fatigue
Menopause
Do you experience any of these symtoms:
Severe fatigue or loss of energy
Weight gain, difficulty losing weight
Depression and depressed mood
Joint and muscle pain, headaches
Dry skin or brittle nails
Brittle hair, itchy scalp, or hair loss
Irregular periods or PMS symptoms
Constipation or diarrhea
Puffiness in the face and/or extremities
Elevated levels of LDL (the "bad" cholesterol) and heightened risk of heart disease
Are there any activities you participate in that are detrimental to your health? Please list them below and whether you are trying to stop.
Have you experienced "negative life challenges" in the past 2 years (i.e. divorce, death of loved one, serious illness for you or loved one, etc.)? Please explain below
What kinds of things are causing you stress in your life right now?
Back
Next
Exercise & Diet History
Are you currently involved in a regular fitness program?
*
yes
no
Please describe
Are you involved in physical activities of daily living (walking, gardening, etc.)?
*
yes
no
Explain what type and how often.
What weight loss programs have you participated in over the past 10 years?
Would you characterize yourself by always trying a new diet or weight loss program?
yes
no
What is your weight loss or gain history over the past 10 years?
How old were you when you started your first weight loss diet plan?
Date you first started THM (approximate is fine)?
-
Month
-
Day
Year
Date
Starting Weight
Back
Next
Personal Goals
Long term goals (where do you want to be in 12 months):
Short term goals:
Weight loss goal:
(keep in mind this is a lifetyle approach and not a race):
Weight goal:
Clothing size:
Health Goals:
Additional Goals:
Back
Next
Coaching Information
Why did you seek out a Trim Healthy Coach?
How did you hear about my services?
What are the top 3 things you want/need from your Trim Healthy Coach?
How would you prefer to connect with your coach? (please indicate preference)
*
phone
email
in person
Zoom
Facetime
Facebook Messenger
Can you receive texts at this number?
Yes
No
May I leave a voicemail?
Yes
No
Facebook ID
Contact Name
How often would you prefer to connect with your coach?
*
weekly
bi-weekly
monthly
Other
How are you best supported? (eg. gentle nudging, "hard" pushes, or somewhere in between)
What are your hindrances (if any) to losing weight, implementing the Trim Healthy Mama Plan, or falling short of your goals?
Back
Next
Resources
What Trim Healthy Mama resources do you have access to?
Original THM Book
Trim Healthy Plan Book
Trim Healthy Table
Trim Healthy Membership Site
Trim Healthy Mama Cookbook
THM Official Facebook Groups
Do you listen to the Poddy?
Do you have their exercise DVDs?
Do you read the E-zine (their online magazine)?
What part(s) of it have you read?
Whole book, or list certain chapters
What special ingredients do you have?
baking blend
stevia
Gentle Sweet
Super Sweet
baobab
collagen
whey protein
matcha
nutritional yeast
liquid/coconut aminos
psyllium husks
psyllium powder
glucomannan (gluccie)
gelatin
MCT oil
THM noodles
peanut flour
oat fiber
Other
What kitchen equipment do you have?
instant pot
slow cooker/crockpot
air fryer
food processor
deep freezer
blender
hand blender
mixer
toaster oven
microwave
Back
Next
Eating/Cooking Habits
Do you (choose all that apply)
Meal plan
Use a shopping list
Keep a stocked pantry
Pre-prep fruits, veggies, dry ingredients, sippers or snacks
Pre-cook and prep meats and/or poultry
Sit down and take time (20-30 minutes) to eat
East meals quickly
Skip breakfast most days
Have a solid bedtime routine
Know how to read a nutrition label
Use the USDA database to look up nutritional info
Know how to calculate NET carbs
Use apps like "My Fitness Pal" and "Diabetes M"
Use (or in the past) a hand-written food diary
Back
Next
Personal Support
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.
Marital Status
Spouse's Name
First Name
Last Name
Spouse's Age
Children living at home: first name and age
Do you have a pet?
Yes
No
Type of pet(s) and name(s)
Back
Next
Who do you relate to?
Which type of Mama do you relate to? (check all that apply)
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 Standard American Diet.
Raw 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-based.
Farm 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..
Submit
Should be Empty: