Name*

Preferred Email*

Preferred Phone*

Describe a typical day (what time do you wake up, what time do you go to work, how do you spend your afternoon/evenings, what time do you go to bed?, etc.)

Do you experience stress in your life? (If so, how often do you feel stressed? And what is the main cause?)

Who do you live with and please describe their eating habits/lifestyle: (Very healthy, somewhat healthy, or not healthy at all)

Do you have a support system? (If so, who?)

What do you do for self-care?

What do you like to do in your free time?

How many hours of sleep do you get on average a night?

Daily Nutrition Habits: (i.e. water intake, eat breakfast, drink soda, fast food, eating while watching tv, slippery slope foods, triggers they may have, etc.)

When did you start to gain weight?

Would you consider yourself a food addict?

Do you currently exercise? (If so, how many days per week? And what do you like to do?)

Failures: (How many times have you tried to lose weight? Why did you fail? Do you feel confident that you can do this?)

Emotional state: (How do you feel about yourself? Why?)

Priorities: (How bad do you want this? On a scale of 1-10 how would you rate it?)

Goal(s): (What do you hope to accomplish while working with me?)

Questions & Comments