Lifestyle FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Anticipated Start DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name *FirstLastBirthdayMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920GenderMaleFemalePhoneEmail *AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeOccupationSmoker? How many per dayUnits of alchol per week:Current WeightIdeal weight and when last at this weightHeaviest weightHeightWaist (inches and cm) at your navelHips (inches)Hours of exercise per weekType of exerciseMedical history/health concerns/medicationHow would you describe your overall wellbeing right nowAny digestive problems? (e.g. heartburn, bloating, wind etc)What nutritional supplements do you take?Rate your eating Selected Value: 01 is unhealthy – 10 healthyStress Levels Selected Value: 01 is low – 10 highEnergy Levels Selected Value: 01 is low – 10 highConcentration Levels Selected Value: 01 is low – 10 highSelf-esteem Selected Value: 01 is low – 10 highSleep quality Selected Value: 01 is low – 10 highSkin health Selected Value: 01 is poor – 10 goodPMS/menopausal symptoms Selected Value: 01 is poor – 10 No symptomsCraving Levels Selected Value: 01 is low – 10 HighWhat would you like to achieve: Health, Weight, FitnessBy when? Do you have a specific goal in mind?What are your top 3 reasons for wanting to change now?What are the top 5 most important things to you in your life?List all the advantages of you achieving your goals now. How will your life improve?Please provide details of other healthy eating regimes you have triedWhat usually gets in the way of your success / what are your barriers?How can you overcome these barriers?What are your biggest concerns regarding your health / weight?What is the best way to support you? What do you most need?What are your hobbies – what do you love doing?What other areas of your life would you like to improve?On a scale of 1 (low) to 10 (high) how important is it for you to be healthier: Selected Value: 0On a scale of 1 (low) to 10 (high) how important is it for you to be slimmer: Selected Value: 0On a scale of 1 (low) to 10 (high) how important is it for you to be fitter: Selected Value: 0On a scale of 1 (low) to 10 (high) how committed do you feel towards your goals? Selected Value: 0Do you have any other questions, anything else you would like to mention?CommentSubmit
