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TRANSFORM: MIND, BODY & SPIRIT
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Shred 10
F.I.T. Quiz
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TRANSFORM WELLNESS INTAKE FORM
Its Time To Transform Your Life!
First Name
Last Name
Email
Preferred Contact Phone #:
How did you hear about us?
Birthday
Height
Weight One Year Ago
Current Weight
Ideal Weight
History of family problems
Occupation
Please rate your stress levels on a scale of 1-10 (10 being high)
How would you rate the pace of your life
Very fast paced (busy)
Little free time (moderate slow)
Relaxed
How do you sleep at night?
How much water do you drink per day?
How much water do you drink per day?
Do you eat when you are
Bored
Stressed
Both
Are you addicted to any of the following?
Caffeine
Sugar
Alcohol
Cigarettes
Do you have challenges with portion control?
Yes
No
How often do you exercise?
Never
Rarely (A couple times a year)
A couple times a month
Weekly
What Type of exercise do you like?
Have you tried health/weight loss/nutrition/wellness programs in the past? If so, which, and were they successful?
Do you take any medications/supplements, if so please list:
Please detail the foods you typically eat for breakfast
Please detail the foods you typically eat for lunch
Please detail the foods you typically eat for dinner
Please detail the foods you typically eat for snacks
Please detail the foods you typically eat for Beverages
What are your major health concerns?
What would you like to be different 6 months from now?
What is holding you back from being healthier?
Would support with your health and wellness goals be of interest to you?
Yes
No
Do you prefer grou or individual support?
Group
Individual
Is there anything else that is important to know regarding your health that you have not mentioned?
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