CREATING HEALTH: Body,Mind,Spirit,Finances

Name*

Phone*

Format: (000) 000-0000.

Email*

Preferred Method of Contact*

Address*

Street Address

CityState / Province

Postal / Zip Code

Referred From?

STEP 1: AWAKEN

1. What would you like to accomplish with your health? This could be weight-loss, improved sleep, better habits, more muscle, less medications, better response to stress, etc. *

2. What is your main motivation for wanting to make changes to your health? Energy, Health related issues, Relationships, Activities, How you will feel, etc*

3. Can you tell me about a time in your life when you were healthier? What has changed between then and now?*

4. Tell me about your health: Do you have any allergies, health conditions, you take that could influence which Program we choose?*

5a. Are you Pregnant?

NoYes

5b. Are you Nursing?

NoYes

6. Are you taking any medication for:

7. Do you have any of the following:

*Lithium: The healthcare provider may wish to adjust frequency of lab work for the Client and monitor. Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication. Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.

STEP 2: DAILY ROUTINE & HABITS

How many hours of sleep do you get in a typical night?*

How would you describe the quality of your sleep?

On a scale of 1-10, what is your energy level throughout the day?*

How would you describe the quantity & quality of the activity you do each week?

How many hours a day do you sit?

How many days a week do you exercise? (0 - 7 days)*

What types of physical activity do you enjoy?

On a scale of 1-10, how fulfilled are you?*

On a scale of 1-10, how much do you worry?

What area of your life tends to be the biggest stress for you?

What do you do for work?*

On a scale of 1-10, how much do you enjoy what you do?*

How many meals and snacks do you eat per day?*

When do you eat your first meal of the day?

How many times a week do you eat out? And where?

How many ounces of water do you drink per day?*

Do you drink other beverages? Coffee, soda, alcohol, tea, etc.

If so, how often and how much?

Age*

Height*

How much do you currently weigh?*

What would you consider to be a healthy weight for you?*

Have you tried to lose weight in the past?*

What has been difficult for you about losing and maintaining weight?*

On a scale of 1-10, how healthy would you rate your surroundings? (This includes: healthy friendships, supportive family, keep junk food in the house, etc*

Is there anyone in your life who would like to get healthy with you?*

Is there anything else you think I should know about your health?*

Faith, Family, Fitness Coaching

Health Assessment & Metabolic Self-Check

SLEEP & ENERGY

MOTION

MENTAL/EMOTIONAL/SPIRITUAL

FOOD & HYDRATION

WEIGHT MANAGEMENT

SURROUNDINGS

Are You Ready to BE Transformed?

WRAPPING IT UP