Planning Your Success
How did you find out about us?
Referred by a friend
Web or Google search
Arthritis, joint pain
Pre-diabetes, diabetes or blood sugar issue
Heart disease or issue
Cancer of any type
Mental health or mood issues
Other health concerns:
Body shape concerns:
Clothing too tight
Hips and thighs
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?
Confidence and self esteem
Consistent energy through the day
Increase ability to be more physically active
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?
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?
Dessert / Snack
Do you consume alcohol?
Do you consume soft drink, juice or flavoured milk?
Do you buy take-away foods sometimes?
Do you eat out at restaurants sometimes?
Are there any times during the day you have an energy slump?
Are you ready to make food changes in order to achieve your goals?
What is your current clothes size?
What size would you like to see yourself in again?
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?
On a personal level, how important is it for you to lose weight right now?
1 - not important
10 - very important
Plan of Action
For phone or video coaching, which day/s would suit you best?
What time/s would suit you?