Name
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First Name
Last Name
Email
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What are your goals for the next 6 weeks?
To get stronger? To lose weight? To feel more confident? To see more definition? To feel more energetic? etc.
When did you start gaining weight/dealing with whatever reason you decided to do this challenge?
Childhood? Pregnancy? When starting medications?
What have you tried in the past to lose weight? i.e.- diet and exercise? Any formal programs such as Jenny Craig, Atkins, Nutrisystem?
What seems to have been the issue with losing weight/achieving total body wellness on these above programs?
Did you not lose? Did you lose and gain it back? Did time constrain you? Did you get bored of the food? Etc?
Who is your support system for this 6 week challenge?
Regarding your diet, what do you think is something you know you eat too much of or can improves on?
i.e.- Do you eat too many carbs? Too many sugars? Too large of portions? Etc?
What is your work schedule like?
Do you get or take breaks? Is it dictated by kiddos and their whim? Etc.
Do you have any feelings of emotional eating, addiction or binge eating?
What is your short-term goal in the next 3-6 months regarding you fitness journey?
What is your long-term goal in the next 6 months to a year?
What do you see as the biggest challenge in your way to being successful?
i.e.- limited on time? Limited on finances? Cooking? Self control? Lose but gain back? Explain.
What is your typical day include the info in the prompts below
Time of wake up
Time of first meal and what you eat
Time of second meal or snack and what you eat
Time of third meal or snack and what you eat
Time of fourth meal or snack and what you eat
Do you skip meals? If so which ones?
How late do you eat your last meal and what time do you go to bed at night?
How much water do you drink in a day?
Any medical conditions you have been diagnosed with that you would like me to know about?
i.e.- high blood pressure, high cholesterol, diabetes or prediabetes, PCOS (females), low testosterone (males), insomnia, sleep apnea, anxiety, depression, chronic stomach issues, chronic yeast infections, chronic sinus infections, irregular menstrual cycles, snoring or excessive daytime sleepiness or concern for sleep apnea?
Any medications you are currently taking that you would like me to know about?
Have you had any previous weight loss surgeries?
i.e. -Gastric bypass, lap band, gastric sleeve?
Is there anything else you think is important for me to know about you?