Your Health Journey - First Steps

Exploring Your Health Journey

with Michelle Fields
First Name*
Last Name*
Email*
example@example.com
Date*

MonthDayYear
Today's Date
Address
City
State*
Two Letter Abreviation
Zip Code
Phone Number*
What time zone are you in?

ESTCSTMountainArizonaPST
Date of Birth

MonthDayYear
Date
Who referred you to our program?
If you were referred, name of person who referred you.
Did you meet me at an event?

Crunch FitnessBougie ExpressPlanet FitnessWGWE 2025The Webb's Place Health ExpoOther
Preferred Method Of Initial Contact

TextCallEmail
Awaken...Discover where you are and where you want to be!
I coach people in three areas — healthy body, healthy mind, healthy finances**. Please rate those in order of importance for you.*
**OPTAVIA makes no guarantee of financial success. Success with OPTAVIA results from successful sales efforts, which require hard work, diligence, skill, persistence, competence, and leadership. Please see the OPTAVIA Income Disclosure Statement (https://optavia.me/IDS) for statistics on actual earnings of Coaches.
What are you most interested in at this moment?

Weight LossCreating Healthy HabitsBuilding Muscle and/or Gaining WeightMedically Supported Weight Loss Options (GLP1 shots)Other
Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)*

0/330
Describe where you would like to be in your Health...*

0/330
Please describe WHY you are interested in getting healthy. (What is your main Motivation, ie relationships, activities, how you feel, etc.)*

0/330
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?*

0/330
Medical
Are You Pregnant

YesNo
Are You Nursing

YesNo
If yes, how old is your baby
Do you have the following

Diabetes - Type 1Diabetes - Type 2High Blood PressureGout
Are there any food or other allergies that I should be aware of?

0/160
Are you taking any medications for:

DiabetesHigh Blood PressureHigh CholesterolThyroid**Lithium*Coumadin (Warfarin)***
Are you taking other medications/supplements or have other medical conditions that could influence which program we choose?*

0/185
*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.
Have you ever used or considering using medically support weight loss (GLP1 shots or surgery)? *

0/185
SLEEP
How many hours of sleep do you typically get?
What time do you typically go to bed?
What time do you typically wake up?
How is your quality of sleep?
Do you wake up feeling rested?
HYDRATION
How much water do you drink each day?
How much Coffee?
How much Soda?
How much Tea?
How much Alcohol?

0/50
MOTION
How would you rate your energy level? (on a scale of 1-10)
How many times a week do you exercise?
What physical activities do you participate in?
Are there things you can't do that you would like to be able to?
STRESS
How would you rate your stress level? (on a scale of 1-10)
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
EATING HABITS
How many meals per day do you eat?
When do you eat your first meal?
When do you eat your last meal?
Do you snack between meals?
What kind of snacks?
How many times a week do you eat out?
Where?
WEIGHT
Current Weight
Goal Weight
Height
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?*

0/200
SURROUNDINGS
How healthy would you rate your surroundings? (on a scale of 1-10)
Do you have healthy & active friends, supportive family, keep junk food in the house, etc?
Is there anyone in your life who would like to get healthy with you?
Should be Empty:

Exploring Your Health Journey