First Name

Last Name

Email *

Address

City

State

Postal code

Phone *

Birth Date

How did you hear about our program?

What do you hope to accomplish with your health?

Weight Loss

Confidence

Energy

Better Sleep

Feel Better

Be more present with my family and friends

Peace of mind about my health

Discover Where You Are and where you want to be:

Tell me where you are now with your health. (weight, sleep, stress, energy, medical concerns, etc.)

If you had total control and could guarantee you would feel amazing, tell me about your health then... (How much weight would you lose How would it impact your mentally, emotionally, physically?)

If you were to lose that amount of weight and feel THAT GREAT... What would that allow you to say yes to? What activities would you do more of? What would the confidence, energy, or mental clarity it brings allow in your life?

Medical

Gender

Male

Female

If female, are you nursing?

Yes

If yes, how old is your baby?

Medical Info

Diabetes

High Blood Pressure

High Cholesterol

Thyroid*

Lithium**

Coumadin (Warfarin)***

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?

Do you wake up feeling rested?

Hydration

How many ounces of water do you drink each day?

How much coffee and/or soda do you drink each day?

How many alcoholic drinks do you consume in a day/week?

Motion

On A Scale of 1-10 How would you rate your energy level?

Life & Stress

How would you describe your stress level on average?

What do you do for work and fun? How much do you enjoy your current work?

Eating Habits

How many meals do you eat per day?

Dl you snack Between Meals?

Yes

If you are a snacker, what times of day and what types of snacks do you choose?

How many times a week do you dine out?

What types of restaurants do you typically eat out at?

Weight Info

Current Weight

Goal Weight

Height

On a scale of 1-10 (10 meaning ready to go!), how motivated are you to start working on your health goals?

What has been most difficult about losing/maintaining weight in the past?

Who are the top 3 people who will support you in this journey?

Who are the people who might be a stumbling block to your progress?

Who are the top 3 people you would like to get healthy with you?