Mon-Fri 8a-5p

Sat-Sun By Appt

Exploring Your Health Journey

With Coach Giuseppe!

Full Name *

Phone *

Email *

Address

City

State

Zip code

Date of birth *

Who referred you to our program? *

Preferred Method Of Initial Contact *

Text

Call

Email

Tell us a little more about yourself...

Describe where you are in your Health now... (Weight, sleep, stress, energy, etc) *

Describe where you would like to be in your Health... *

Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.) *

When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)? *

Medical

Are You Pregnant

Yes

No

Are you nursing?

Do you have the following

Diabetes - Type 1

Diabetes - Type 2

High Blood Pressure

Gout

Are there any food or other allergies that I should be aware of?

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? *

What time do you typically go to bed? *

What time do you typically wake up? *

How is your quality of sleep? *

Do you wake up feeling rested? *

Hydration

How much water do you drink each day? *

How much Coffee? *

How much Soda? *

How much Tea? *

How much Alcohol? *

Motion

How would you rate your energy level? (on a scale of 1-10) *

How many times a week do you exercise? *

Are there things you can't do that you would like to be able to? *

What physical activities do you participate in? *

Stress

How would you rate your stress level? (on a scale of 1-10) *

What do you do for work? *

How much do you enjoy what you do? *

Are there other stressors in your life? *

Eating Habits

How many meals per day do you eat? *

When do you eat your first meal? *

When do you eat your last meal? *

Do you snack between meals? *

What kind of snacks? *

How many times a week do you eat out? *

Where do you usually eat out? *

Weight

Your current weight? *

What is your goal weight? *

What is your height? *

Have you tried to lose weight before? *

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

Surroundings

How healthy would you rate your surroundings? (on a scale of 1-10) *

Do you have healthy & active friends, supportive family, keep junk food in the house, etc? *

Is there anyone in your life who would like to get healthy with you? *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Trilogy Coaching

(731) 325-3954

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Exploring Your Health Journey

With Coach Giuseppe!