Health & Wellbeing Form

Healthy Living Q&A

Kathy McClare, CEO at Healthy with Kathy
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
Age
How did you hear about our programs?
Please describe your WHY to becoming a healthier version of yourself. (What is your main motivation? Relationships, activities, how you feel, etc)
When was the last time you remember feeling your best in your health or being at your ideal weight or size? (if that is part of your goal)
Health Goals and Habits
Are you pregnant?
Are you nursing?
If yes, how old is your baby?
YESNO
How many hours of sleep do you typically get per night?
What time do you typically wake up?
How is your quality of sleep? Do you rise feeling rested?
How much water do you typically drink per day?
CoffeeSodaTeaAlcohol
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
Do you currently exercise? If so, how many times a week?
What physical activities do you participate in?
How would you describe your daily activity level?
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Are there any other stressors in your life?
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
Weight
Current Weight: (if you wish to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
Height:
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who is empowered to get healthy with you?
Should be Empty:

Healthy Living Q&A

Health Goals and Habits

Weight