Journey to Health
Health is an outfit that looks different on everybody, lets figure out what's best for you!
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Facebook/IG Handles
Preferred Method of Contact (check all that apply)
Call
Text
Email
FB Messenger
IG Message
How did you hear about me?
If Referred - Name of person I can thank!
Select ALL that Apply! and Then we'll dive Deeper!
Weight Loss is most important to me
My anxiety/stress is often through the roof
No matter what I do, I can rarely get enough sleep
My Immune system could be better
I'm experiencing perimenopause/menopause symptoms
I feel like I've tried everything to lose weight
My joints hurt most/all of the time
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Truth Talk
Current State of Health
On a scale of 1-10 (1 lowest, 10 highest) What is your daily STRESS level at?
What area of your life tends to bring on the most stress? (example: work, school, kids, marriage, finances, health)
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On a scale of 1-10: How is your daily energy? (10 being INCREDIBLE energy all day!)
If you are not at a 10 for your energy - What time of day do you hit that low and how do you respond to it? (napping, snacking, energy drinks, coffee, etc)
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How are you sleeping at night? How many QUALITY hours do you get a night? Do you feel rested when you wake up? Do you use a sleep tracker?
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Exercise
How many days per week do you exercise and for how long? What's your favorite movement of choice?
On Average how many steps per day?
under 5000
5000-8000
8000+
Are there things you can't do that you would like to be able to?
Eating Habits
Check all that apply!
I enjoy cooking healthy meals.
I can eat the same thing over and over.
I prefer to eat out.
I read nutrition labels.
I stop eating when I'm full.
I tend to overeat.
I eat sweets often.
Give me something crunchy and salty over sweet treats.
I need caffeine right away in the morning. (coffee, soda, energy drink, tea)
I eat breakfast everyday/most days.
I drink a minimum of 60 oz of water daily.
I know how to track my macros/calories.
I often eat right before bed.
Is there anything else you'd like to share about your eating habits, nutrition choices?
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Body Stats/Goals
Current Weight
Goal Weight
Height
What has been most difficult about losing/maintaining weight in the past?
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What is 1 positive healthy habit you have NOW that you will keep doing?
What is 1 negative habit/pattern that you have that will take away from your desired results if left unchanged?
What is 1 area of your body that you LOVE when you look into the mirror?
Who's your biggest cheerleader, supporter, friend - The one who will encourage you to keep going towards your goals?
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Please list ALL Medications, Supplements and Injuries.
Mental and Spiritual Wellbeing play a big role in overall health. Please select all that apply.
I journal most days.
I spend time praying.
I meditate daily.
I keep a gratitude list.
I attend personal growth events.
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