Planning Your Success
First Name
*
Last Name
*
Email
*
How did you find out about us?
Referred by a friend
Web or Google search
Facebook
Instagram
Signage
Previous member
Doctor referral
Another way
Health concerns:
Arthritis, joint pain
Pre-diabetes, diabetes or blood sugar issue
Blood pressure
Cholesterol
Heart disease or issue
Cancer of any type
Immune function
Reduce medication
Mental health or mood issues
Other health concerns:
Body shape concerns:
Clothing too tight
Tummy
Hips and thighs
Flabby arms
Tone up
Anything else:
Current weight in kg
Goal weight in kg
When were you last at your goal weight?
Do you have a specific reason and/or date to achieve your goal weight?
What are you looking forward to doing once you've hit your goal weight?
Wellbeing improvements:
Confidence and self esteem
Consistent energy through the day
Less bloating
Concentration
Happiness
Increase ability to be more physically active
Relationships
Sleep better
Stress management
All of the above
Other wellbeing improvements:
Your most recent weight loss attempt
What did you do to try to lose weight?
When was that?
How long did you continue with your efforts?
Not long
For a while
A long time
How much weight did you lose?
How long did you keep the weight off?
What did you like about it?
What did you dislike about it?
In the past, what, if anything, got in the way of you reaching and maintaining your weight?
What did you eat yesterday?
Breakfast
Snack 1
Lunch
Snack 2
Dinner
Dessert / Snack
Do you consume alcohol?
Yes
No
Notes
Do you consume soft drink, juice or flavoured milk?
Yes
No
Notes
Do you buy take-away foods sometimes?
Yes
No
Notes
Do you eat out at restaurants sometimes?
Yes
No
Notes
Are there any times during the day you have an energy slump?
Yes
No
Notes
Are you ready to make food changes in order to achieve your goals?
Yes
No
Notes
Clothes
What is your current clothes size?
What size would you like to see yourself in again?
Motivation
How long have you been thinking about starting a program?
Did anything happen recently to prompt your decision to enquire about our program now?
Will others at your home support your plan to lose weight?
Yes
No
Notes
On a personal level, how important is it for you to lose weight right now?
1 - not important
2
3
4
5
6
7
8
9
10 - very important
Plan of Action
For phone or video coaching, which day/s would suit you best?
What time/s would suit you?
Early morning
Mid morning
Afternoon
Early evening