First Name *

Last Name *

Email Address *

Which store is your wellness appointment scheduled at? *

Select your Wellness Coach *

How old are you? *

How tall are you? (inches) *

What is your current weight? (lbs.) *If you would like to weigh in at your appointment, you may leave this part blank

Gender *

Do you have any preexisting medical conditions that you think your coach should be aware of (ex: diabetes, heart conditions, etc.)? *

Yes
No

Please explain.. *

Do you have any dietary restrictions (vegetarian, gluten-free, etc.) or food allergies that your coach should be made aware of? *

Yes
No

Please list any dietary restrictions/food allergies here: *

What is your overall health goal? *

Exaplain your goal here: *

What is your motivation for reaching this goal? (aka your 'why') *

What has been the biggest obstacle/challenge with reaching your goal? *

What other programs or coaching (if any) have you tried? *

How would you best describe your current lifestyle? *

How would you best describe your current phyical activity level? *

What type of physical activity do you ENJOY doing? (Walking the dog, swimming, lifting weights, etc.) *

Which of the following best describes your current eating schedule/habits? *

How many days a week do you typically eat out at a restaurant or order takeout? *

How many days a week do you or a family member cook at home? *

What does a typical breakfast look like for you? Not your best day or your worst day, just the normal, average day. *

What does a typical lunch look like for you? *

What does a typical dinner look like for you? *

Do you snack throughout the day? *

Yes
No

What do you typically snack on? *

Do you drink alcohol? *

Yes
No

What type of alcohol and how often? *

Do you drink any coffe/tea? *

Coffee
Tea
Both
No

How many cups a day? *

How do your take you coffee? *

How many cups a day? *

How do your take your tea? *

How many cups a day? *

How do your take your coffee and tea? *

How many 8-ounce glasses of water do you typically drink in a day? *

How many days of the week do you find yourself waking up feeling restful from your previous night's sleep? *

How motivated do you currently feel about working towards your wellness goal? *

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Thanks for getting in touch!

Thanks for getting in touch!

Haily's Chicken Katsu

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