Kelly Otake - Health Form

Exploring Your Health Journey

with Kelly Otake
Full Name

First NameLast Name
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
How did you hear about me or our programs?
Who referred you to our program?
Preferred Method Of Initial Contact
Awaken... Discover where you are and where you want to be!
Describe where you are in your Health now...(Weight, sleep, stress, energy, etc)
Describe where you would like to be in your Health...
Please describe WHY you are interested in getting healthy. (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's part of your goal)?
MEDICAL
Are you Pregnant
Are You Nursing
If yes, how old is your baby?
Do you have the following
Are there any food allergies or other allergies that I should be aware of?
Are you taking any medications for:
Are you taking other medications or have other medical conditions that could influence which program we choose?
*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.
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, Tea or Caffeine?
How much Soda?
How much Alcohol?
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 / exercise activities do you participate in?
How would you describe your daily activity level?
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 any 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 in between meals?
What kind of 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)
Where do you go?
WEIGHT
Current Weight:
Goal Weight:
Height:
Have you tried to lose weight before?
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?
Should be Empty:

Exploring Your Health Journey

Awaken... Discover where you are and where you want to be!

MEDICAL

SLEEP

HYDRATION

MOTION

STRESS

EATING HABITS

WEIGHT