Name * First Name Last Name Phone (###) ### #### Email Birth Date Occupation/Work Hours List All Medications: List any health problems or physical limitations: How many hours of sleep do you get per night? Is your sleep restful? On a scale of 1-10, what level is your stress? Explain stress here: How do you cope with stress? On a scale of 1-5 (5 most likely), how do you rate your readiness to make lifestyle changes? How do you rate your confidence to make lifestyle changes? Current weight: Height: What has been your lowest and highest weights as an adult? Describe any weight changes (gain or loss) in the past 2 years: Have you dieted in the past for weight loss? What have you done? What makes it hard for you to lose weight and keep it off? What has helped you lose weight? How much weight would you like to lose? How will you benefit from this weight tloss? What is the most physically active thing you do in a day? Option 1 Option 2 What, if any, regular exercise do you do? Option 1 Option 2 How many days/wk do you exercise? How long? What level of intensity is your exercise (light, moderate, heavy)? List any physical limitations to exercise: Do you track your steps? What is your average per day? Please describe your typical food/meal/beverage intake? Breakfast/Lunch/Dinner/Snacks How often do you eat out at restaurants/fast food? Who does the grocery shopping in your household? Who plans/prepares meals in your home? What would you like to change about your diet? Do you eat in response to your emotions? Check the current statement that best describe your eating habits: I usually don’t realize I’m hungry until I’m ravenous. I’m often not satisfied until I’m stuffed. I can’t say no to foods like chocolate or chips. OptionI follow the “see food diet”: When it’s there, I eat it. I usually quit eating when I feel like I’ve comfortably had enough. I always worry whether the foods I eat will make me gain or lose weight. The only way I know to stop eating is when the plate is “clean”. I don’t really think about what I eat, I just grab whatever is available. Most of the time, I eat only when I’m hungry. I often get so hungry that rich foods are more appealing than lighter ones. I usually quit eating because I lose interest in food as I become satisfied. I stop eating because I think I should. I like nutritious foods, but I forget to have them. I feel that I can never get enough of certain foods I think I shouldn’t eat. Describe your typical weekend, if different than meals for the week: How would you describe your satisfaction with your body? What specific outcomes are you looking for from this experience? Describe your ideal coach (nurturing v. no-nonsense): Is there anything you'd like me to know? Thank you! Metabolic Reset Metabolic Reset Metabolic Reset
