Online Coaching Evaluation

Wellness Evaluation Form
E-mail
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Full Name
First NameLast Name
Phone Number
Area CodePhone Number
Best Form of Contact
Birth Date
MonthDayYear
Height (cms)
Weight (kgs)
How did you hear about us?

How much weight do you think you need to LOSE/GAIN?
Why do you want to LOSE/GAIN this weight?
What other programs/products have you tried in the past?
Why do you feel that these other program(s) did not work?
What is your biggest struggle when trying to LOSE/GAIN weight?
How many times a day do you eat?
Do you drink alcohol?
What is your current job?
Are you active during the day?
What time do you normally exercise?
Do you have a family?
Who is the cook in your house?
Are you willing to food prep?
Do you take vitamins or any type of nutritional supplements currently?
How many litres of water do you drink daily?
Do you eat out? How often? (Times/week)
Where is your energy level, on a scale of 1 to 10? (1: Dragging / 10: Bouncing)
Are you currently taking any prescription medication?
Do you regularly exercise? If YES, what type and how often?
If YES, for what?

AcneAlcohol ConsumptionAllergiesAlzheimer's DiseaseAnemiaAnxietyArthritisAsthmaBack PainBladder InfectionHigh Blood PressureCaffeine ConsumptionCaffeine SensitivityCalcium DeficiencyCancerCeliac DiseaseChronic ConstipationChronic FatigueChronic SinusitisCirculation (poor)ColitisCongestive HeartFailureDepressionDiabetes Type OneFibromyalgiaGall Bladder DiseaseGall StonesGoutHeartburnHeart DiseaseHerniaHigh CholesterolHyperactiveHypoglycemiaInsomniaIrritable Bowel SyndromeKidney DiseaseKidney StonesLow EnergyLow Sexual StaminaLupusMenopausalMigraine HeadachesMood SwingsMultiple SclerosisNursing MotherPregnantPremenstrual SyndromeOsteoporosisSleep DisorderSmokingStressHigh TriglyceridesWater Retention/BloatingUlcersDiabetes Type Two

Your Typical Daily Diet
What time do you usually wake up?
BREAKFAST (Eat & Drink)
Usual Time
:HourMinutesAM/PM Option
AM SNACK (Eat & Drink)
Usual Time
:HourMinutesAM/PM Option
LUNCH (Eat & Drink)
Usual Time
:HourMinutesAM/PM Option
PM SNACK (Eat & Drink)
Usual Time
:HourMinutesAM/PM Option
DINNER (Eat & Drink)
Usual Time
:HourMinutesAM/PM Option
EVENING (Eat & Drink)
Usual Time
:HourMinutesAM/PM Option

GOALS: WHY do you want to accomplish this? Be as SPECIFIC, DETAILED, and VAIN as possible. How do you want your body to look and feel? Which model, actor/actress, or anyone do you want your body to look like? Do you want more confidence? Do you want to be secure in your own body? Really think about this thoroughly.
Should be Empty: