Step 1 of 14 7% Name First Last Occupation AgeCurrent Weight (lbs)Height (in)Neck (in)Waist (in)Hips (in) Goals & Barriers1. Personal GoalsWhat are you hoping to accomplish working together? (Check all that apply) I do not have any goals at this time and/or I do not know my goals Feel better Fit into old clothes Achieve a specific weight target Improve health Become more active Get more involved in my health Increase confidence/body positivity Increase diet/health knowledge Other Please specify your weight target: Please specify your other goal: 2. BarriersWhich factor(s) are keeping you from achieving your weight/health goals? (Check all that apply) Diet knowledge Physical limitations Lack of social support Hunger Cravings Frequent travel Social events Time Daily schedule (e.g.: erratic schedule) Finances Eating habits of others (e.g.: family, coworkers) "Hormonal issues" (e.g.: thyroid; menopause; etc.) NONE of the items above apply to me Other Please specify your other barrier: Eating Habits1. Eating BehavioursPlease check any of following eating behaviours that you notice yourself doing on a regular basis. (Check all that apply) Late night eating Binge eating Grazing (frequent snacking) Infrequent eating (i.e.: eating only one meal a day) Emotional eating Other Please specify your other eating behaviour: 2. Eating "Triggers"Which of the following triggers you to eat when not hungry? (Check all that apply) Family issue Work issues Stress Emotions Boredom Other Please specify another eating trigger: 3. What type of foods do you crave?4. Food choices and/or sensitivitiesPlease check any/all that apply. None Vegan Lactose intolerance Vegetarian Gluten intolerance Allergy Other Please specify your allergy(ies): Please specify any other food choices/sensitivities: Current Diet Summary1. Do you think your current diet is: Well-balanced Imbalanced Where well-balanced would include fruits, vegetables and protein. Contrarily, imbalanced would indicate too much or too little of certain foods. Imbalanced because I don't eat enough: Imbalanced because I eat too much: 2. Average # of meals /day3. Typical portion size(s) small/below average medium/average large/above average 4. Average # of snacks /day 5. Snacking pattern late night between meals "grazing" (throughought day) no pattern I do not snack Other 6. How many times a week do you:Eat out at restaurants?Eat breakfast?Cook meals at home?Grocery shop? 7. Do you normally eat alone or with friends/family? alone with friends/family 8. Where do you grocery shop? 9. Do you read food labels? Yes No What is your favourite meal? (List up to 3)Favourite meal #1 Favourite meal #2 Favourite meal #3 11. What is your favourite restaurant? (List up to 3)Favourite restaurant #1 Favourite restaurant #2 Favourite restaurant #3 12. What 3 foods could you never give up?Food #1 Food #2 Food #3 13. What 3 foods do you refuse to eat?Won't eat food #1 Won't eat food #2 Won't eat food #3 14. Glasses of water you drink /day:15. Do you drink coffee? Yes No How many cups of coffee /day?Typical size of coffeeSmallMediumLarge16. Do you drink sodas? Yes No How many cans/glasses of soda /day? 17. Have you tried any popular diets? Yes No Please specify which ones and for how long: (Up to 3 most recent)Diet #1 How long did you stick with diet #1? (Weeks)What was your experience with diet #1?Diet #2 How long did you stick with diet #2? (Weeks)What was your experience with diet #2?Diet #3 How long did you stick with diet #3? (Weeks)What was your experience with diet #3? Sleep & Stress ManagementSleep1. On average, how many hours do you sleep (total)?2. How many hours of UNINTERRUPTED sleep do you get most nights?3. When do you fall asleep?Before 9:00 PM9:00 PM9:30 PM10:00 PM10:30 PM11:00 PM11:30 PM12:00 AMAfter midnightVariable (shiftwork)4. When do you wake?Before 5:00 AM5:00 AM5:30 AM6:00 AM6:30 AM7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AMAfter 11 AMVariable (shiftwork) Stress5. How do you manage stress?(Please check all that apply.) None Yoga Meditation Jornaling Talking / affirmations Exercising Other Please specify what else you do to manage stress: 6. How would you rate your stress on a daily basis?(On a scale of 1 - 10)Please enter a number from 0 to 11.7. Do you consider yourself a positive / optimistic person? Yes No Exercise Info1. Describe your daily activity (check the one that most applies to you): Sedentary - Spend Most of the Day Sitting (Bank Teller, Desk Job) Light activity - Spend A Good Part of the Day on Your Feet (Teacher, Salesman) Active - Spend a Good Part of the Day Doing Physical Activity (Waitress, Mailman) Very active - Spend Most of the Day Doing Heavy Physical Activity (Messenger, Carpenter) 2. How many days per week do you exercise?Please enter a number from 0 to 7.3. How intense is your exercise session? (check the one that most applies to you): Light - I can hold a conversation while working out and do not break a sweat. Moderate - I am breathing very hard and challenge myself. Difficult - Always break a sweat and have an elevated heart rate. I cannot hold a conversation. Intense - Don't talk to me, don't look at me. I'm here for a purposes and I might die today! 4. How many minutes per exercise session? Contact InfoEmail(Required) CellHome PhoneWork PhoneClient Release I UNDERSTAND THAT THE COACHING I AM RECEIVING IS NOT A SUBSTITUTE FOR PSYCHOLOGICAL OR MEDICAL CARE. I understand that Miriam will provide me with professional nutritional evaluation, coaching, and support for the purpose of enhancing healthy habits. I understand that this evaluation, coaching and support is not intended as a diagnosis, treatment, prescription or cure for any disease, mental or physical, and is not intended as a substitute for regular medical care. I confirm that I am in good health and have consulted a physician prior to starting or continuing an eating and/or exercise program. I understand that weight loss results are not guaranteed. This agreement is being signed voluntarily and not under duress of any kind. Signature(Required)Please use your stylus / finger / mouse to sign your name in the rectangle below.Date(Required) MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. Δ
