Health Consult Form
Jennifer Worten
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Best date to contact you so we can chat about your goals and the program? I will confirm this with you.
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-
Month
-
Day
Year
Date
Best time to contact you?
*
Hour Minutes
AM
PM
AM/PM Option
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where did you hear about me?
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Facebook
Family or friend
Instagram
Other
Do you already have a coach you're working with?
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Yes
No
Tell me a little about yourself. What do you do for work? What are your hobbies?
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Your specific goals
Help me get to know your goals so I can better serve you!
I want to improve in the following areas:
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I want to lose weight
I need to tone up
Overall health
Other
What are you looking to accomplish in your health? What are your goals?
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What is your why? What is your main motivation for wanting to get healthy? Is there an event you're working towards? Do you want to fit in your clothes better? Do you want to clean up your lifestyle? Do you want more energy? Be specific!
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My current weight is
blanks
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field. My goal weight is
blank
*
Have you tried to lose weight in the past? What has been difficult for you about losing and maintaining weight?
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Do you have any of the following?
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Please Select
High Blood Pressure
Diabetes Type 1
Diabetes Type 2
Gout
Gluten Intolerance/Allergy
Soy Intolerance/Allergy
Food Allergies
Are you taking any medications for
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Diabetes
High Blood Pressure
Lithium
Thyroid
Coumadin
None of the above
Other
Do you have any of the following?
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High Blood Pressure
Diabetes Type 1
Diabetes Type 2
Gout
Gluten Intolerance/Allergy
Soy Intolerance/Allergy
Food Allergies
None of the above
Other
If you answered yes to any of the medications or conditions above, please explain. If you answered no, type NA
*
Are you currently pregnant or breastfeeding?
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Pregnant
Breastfeeding
No
Dietary Analysis
Please complete these questions in order for me to provide a proper dietary analysis. Based on the information provided, I will be able to match a personalized plan designed just for you.
Do you....
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Rows
Always
Sometimes
Never
Eat out
Drink 8 glasses of water a day
Have 6 healthy meals a day
Drink alcohol
Drink soda
Daily Routine & Habits
How many hours of sleep do you typically get each night?
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On a scale of 1-10 how would you rate your energy level throughout the day?
*
Are you currently working out?
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Yes
No
If yes, what type of work out do you do? If no, type NA
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How many ounces of water do you drink on a daily basis?
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What do you typically eat in a day? Snack in between meals? Lots of eating out or eating at home?
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Are you currently on a GLP-1 medication for medically-supported weight loss?
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Yes
No
No but I'm interested in hearing more
Is there anyone in your life who would like to get healthy with you? If so, provide their name
*
Thank you!
I'm looking forward to speaking with you! Click the submit button below, and I will be in contact with you.
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