Take my complimentary Health Consultation I look forward to scheduling a call with you. Please tell me a little more about yourself and your health goals by filling out my health consultation form. Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Birthdate MM DD YYYY Preferred Method Of Contact Text Call Email What do you do for work? How did you hear about Coach Ellie and her programs? * (If you were referred, name of person who referred you.) What brings you to Coach Ellie and her programs? (What are you hoping to achieve and/or learn about.) Currently in a Coach Ellie program? Which one? FIT45 FIT10 Beginner FIT10 Intermediate FITabs FITmore WEIGHT Current Weight Height I am looking to: Lose Weight Gain Weight Maintain My Weight MEDICAL Do you have the following? (check all that apply) Diabetes - Type 1 Diabetes - Type 2 High Blood Pressure Gout High Cholesterol Insulin Resistance EATING HABITS What's your eating style? I eat 3 meals a day I graze throughout the day I eat 3 meals and several snacks a day How many times per week do you eat out/order in? 0-2 times per week 3-5 times per week 5 or more times per week Who plans the meals in your household? I plan the meals for myself only I plan the meals for myself and others Someone else plans the meals for me Do you have any food or other allergies or sensitivities? (ie. shellfish, soy, wheat, tree nuts, etc.) HYDRATION How much water do you drink in a day? 8-24 ounces 24-32 ounces 32-64 ounces 64+ ounces Do you drink any of the following regularly? (check all that apply) Soda (diet or regular) Juice Club Soda/Sparking Water Coffee or Tea Sports Drinks Alcohol MOTION How many days per week do you engage in intentional movement/exercise? 0-2 days 3-5 days 6-7 days What physical activities do you participate in? (check all that apply) Strength Training (home/gym) Walking/Running Spin Classes/Indoor Biking Swimming Yoga/Pilates Outdoor Biking Cardio (machines/classes) Do you have any injuries that limit your ability to participate in movement? SLEEP How many hours of sleep do you typically get? Less than 6 hours 6-8 hours 8-10 hours More than 10 hours Do you wake up feeling rested? (yes/no) Yes No Sometimes STRESS How would you rate your stress level? On a scale of 1 to 10, I feel: What do you consider some of the stressors in your life? SURROUNDINGS Do you have a people in your life who support you on this journey? Yes No I'm not sure Thank you!
