LIFESTYLE AND HEALTH QUESTIONNAIRE

Name

First NameLast Name

Email

example@example.com

Phone Number

Area CodePhone Number

Age

Height

Weight

What is your main reason for reaching out to Sheree?*

How would you describe your present state of health?*

excellentgoodfairpoor

Are you taking any prescription medication?*

yesno

If yes, please list:

Do you take any over the counter medication?*

yesno

If yes, please list

Do you take a multi-vitamin consistently?*

yesno

When was the last time you visited a physician?*

Do you have any medical conditions? Please describe:*

What are your dietary goals?*

What was your highest weight and at what age?*

What was your lowest weight and at what age?*

Have you ever followed a diet? Which one?*

Have you tried to lose weight before? Please explain:*

Are you following a special diet now? If yes, please describe.*

What do you consider to be the major issues in your diet and eating plan? ( eating late? snacking? skipping meals? processed foods? )*

How many glasses of water do you drink a day? (a glass is 8oz.)*

Do you have any food allergies or intolerances?*

yesno

If yes, please list:

How many times do you eat out a week?*

What type of restaurants do you eat out at? Please list:*

What foods do you crave?*

Do you have any digestive issues?*

How is your appetite affected by stress?*

increasednot affecteddecreased

How often do you drink alcohol a week?*

12-34-5

Do you smoke cigarettes?

Do you drink caffeinated beverages?*

yesno

If yes, how many per day?*

Do you workout now? Physical activities? Please describe:*

How ready are you to adopt a healthier lifestyle*

yeslikelynot likelyno

What type of exercise interests you?*

How many hours do you sleep on weeknights? weekends?*

⭐️ Please note that completing this screening process enables Sheree to review your application. Providing this information does not guarantee her services.

Please check each box to agree and acknowledge you have read below:

I understand and acknowledge that working with Sheree is an approach to health and weight loss-focused on wellness and fitness for people in good health, and not a medical or diet program but a lifestyle change.I agree to seek the clearance of a physician or qualified medical professional before starting a fitness or a nutrition program.I understand that my success participating depends upon my commitment. I am ready, willing, and able to devote the time needed to complete and fulfill the Program.I understand that Sheree reserves the right to require a medical clearance letter as a condition of participation. I understand that Sheree takes no responsibility for managing my health and is not serving as my doctor, dietician, or other health professional role.