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Exploring YOUR Health Journey
Creating Optimal Health with Coach Melissa Crumb
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Current Snapshot
What are your health goals? (check all that apply)
*
Weight loss
Improve sleep
Better response to stress
Gain energy
Reduce inflammation
Build muscle
Other ____________________________________________________________________________
Tell me how you truly feel right now about how much you weigh and your overall health.
*
What is your main motivation for wanting to make changes to your health? What is your WHY? Relationships, activities, how you will feel, etc *
*
Have you tried to reach these health goals in the past? If so, what have you tried?
*
Current Weight
Current Height in feet & inches
Current Age
Desired Weight
Brief Medical History
Do you have any of the following?
*
Diabetes Type 1
Diabetes Type 2
High Blood Pressure
Food allergies_______________________________
Soy allergy or intolerance
Gluten intolerance or sensitvity
None of the above
Other
Do you have any allergies or other medical conditions that could influence the plan we customize for you?
*
Do you take any of the following medications:
*
Diabetes
High Blood Pressure
Thyroid
Lithium
Coumadin (Warfarin)
None of the above
Lifestyle
How many hours of sleep do get in a typical night?
*
How many days a week do you exercise? (0-7)
*
Describe your workouts. Include length of workouts and types of workouts, i.e. cardio, weightlifting, etc. *
*
How many ounces of water do you drink per day?
Do you drink other beverages, such as:
coffee
soda
tea
wine
beer
alcohol
How many cups of coffee do you drink? And how do you like it?
1-2 cups
3-4 cups
5+ cups
Black
Creamer ONLY of any kind
Sweetner ONLY of any kind
Creamer and sweetener
How much soda/ice tea/energy drinks/other non-alcoholic beverages daily?
How much alcohol weekly or monthly do you consume? What are your drinks of choice?
*
How many meals and snacks do you eat per day?
How many times a week do you eat out? And where? (include fast food)
*
The average American spends approx. $15-$20 a day/person on groceries, beverages, supplements, snacks, dining out, etc. What would you guesstimate is your average?
*
$10
$15
$20
$25+
Females only
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Final Thoughts
On a scale of 1-10, how committed are you to getting to your health goals?
Is there anyone in your life who you would like to get healthy with you? *
Coach use only: Current BMI______________
Healthy
Overweight
Obese
Extremely Obese
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