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Best Life With Kellie - Health Survey
Kellie Collet- Certified Health Coach
Date
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Best number to reach you
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
How did you hear about me or 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)
I am interested in:
Maintaining a healthy weight
Losing weight
Better sleep
Increasing energy
Improved eating habits
Ongoing support to reach your health goals
Improved mindset
Other
Medical
Do you have any of the following?
Diabetes - Type 1
Diabetes - Type 2
High Blood Pressure
Gout
Kidney Disease
PCOS
Are you taking any medications for:
Diabetes
High Blood Pressure
High Cholesterol
Thyroid
Blood Thinners
Other
Please list any and all medications or supplements you are taking, and what you may be specifically taking them for.
Do you have any food allergies or dietary restrictions?
Are you currently
Pregnant
Nursing
None
If nursing, how old is your baby?
Sleep
How many hours of sleep do you typically get per night?
What time do you typically wake up/go to sleep?
How is your quality of sleep and do you wake up feeling rested?
Hydration
How much water do you drink per day?
Do you consume any other beverages?
Coffee
Soda
Tea
Alcohol
Energy Drinks
Other
Motion
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?
Sedentary
On your feet
Active
Stress
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?
Eating Habits
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:
Age
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who would like to get healthy with you?
Have you tried other weight loss programs in the past?
Weight Watchers
Nutrisystem
Jenny Craig
Medifast
Keto
Intermittent Fasting
Other
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