New Client Health Evaluation
Name
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Phone
Email
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Preferred Method of Contact
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Referred From?
STEP 1: AWAKEN
1. GOAL: What would you like to accomplish with your health?
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2. YOUR WHY: What is your main motivation for wanting to make changes to your health?
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3. Tell me about a time when you were healthier? What has changed between then and now?
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4. Do you have any allergies / conditions that could influence which Program we choose?
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5a. Are you Pregnant?
No
Yes
5b. Are you Nursing?
No
Yes
STEP 2: DAILY ROUTINE & HABITS
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?
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How would you describe the quality of your sleep?
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Is your energy good during the day or do you tank?
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MOTION
Are you an active person? Do you walk or go the the gym? If so how much?
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What types of physical activity do you enjoy?
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MIND
On a scale of 1-10, how confident are you in your clothes?
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Do you feel coaching on a healthy mindset would help you?
Do you believe you are in control of your health?
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FOOD & HYDRATION
Do you eat one or two big meals or graze throughout the day?
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How long after getting up do you eat your first meal of the day?
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Are you a water drinker? If so, many ounces of water do you drink per day?
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Do you drink other beverages? Coffee, soda, alcohol, tea, etc.
WEIGHT MANAGEMENT
Age
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Height
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How much do you currently weigh?
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What would you consider to be a healthy weight for you?
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Have you tried to lose weight in the past?
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What has been difficult for you about losing and maintaining weight?
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SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (This includes: healthy friendships, supportive family, keep junk food in the house, etc
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Is there anyone in your life who would like to get healthy with you?
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Is there anything else you think I should know about your health?
FINAL THOUGHT
Thank you for reaching out. It isn't easy, I've been there. Reality is though - if nothing changes - nothing changes! So the first step is for us to hop on a call/zoom - we'll tease out your goals and I'll share with you our approach to things (no drugs, no extreme exercise). If we both are confident that we're a good fit, we'll take the next steps to get you started. Your "Future Self" will be very thankful you did! So, let's do this! Type ALL IN below and I'll be in touch!
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