Getting To Know You
Contact Info
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Current Measurements
Current Weight
Height
Bust
Waist
Hips
R Thigh
L Thigh
Have you taken a before picture?
Yes
No
Are you currently pregnant or nursing?
Yes
No
Health Evaluation
DO YOU HAVE NOW, OR HAVE YOU IN THE PAST (check all that apply):
1. A chronic illness or condition
2. Elevated blood pressure
3. Muscle, joint, or back pain
4. Diabetes or Metabolic Syndrome
5. Thyroid condition
6. Polycystic Ovarian Syndrome
7. Hormone imbalances
8. Adrenal fatigue
DO YOU EXPERIENCE ANY OF THESE SYMPTOMS (check all that apply):
1. Severe fatigue or loss of energy
2. Weight gain, difficulty losing weight
3. Depression and depressed mood
4. Joint and muscle pain, headaches
5. Dry skin or brittle nails
6. Brittle hair, itchy scalp, or hair loss
7. Irregular periods or PMS symptoms
8. Constipation or diarrhea
9. Puffiness in the face and/or extremities
10. Elevated levels of LDL (the “bad” cholesterol) and heightened risk of
heart disease
Back
Next
Exercise & Diet History
Are you currently involved in a regular fitness program? If so, describe:
Are you involved in physical activities of daily living (walking, gardening, etc.)? If so,what type and how often?
What weight loss programs have you participated in over the last 10 years?
Would you characterize yourself by always trying a new diet or weight loss program?
Yes
No
What is your weight loss or gain history over the last 10 years?
How old were you when you started your first weight loss diet plan?
What is your biggest health concern or challenge right now?
Back
Next
Personal Goals
Long Term Goals - List Top 3: (Where do you want to be in 12 months?)
Short Term Goals - List Top 3:
Weight Loss Goal: (Keep in mind this is a lifestyle approach and not a race)
Do you have a weekly weigh in day?
Yes
No
Health Goals:
Additional Goals:
Back
Next
Coaching Information
Why did you seek out a Trim Healthy Mama Coach?
How did you find out about Coach Becky?
If you’ve done THM in the past, when did you begin, and what’s your THM history?
What are the top 3 things you want/need from your Trim Healthy Mama Coach?
What are your hindrances (if any) to losing weight, implementing the Trim Healthy Mama Plan, or falling short of your goals?
Back
Next
Personal Support
Do you feel your family and friends support your decision to improve your health?
Yes
No
Sometimes
Some of them do
Do you have a spouse, family member, or friend following the THM Plan? Please specify:
How would you prefer to connect with your coach? (Please indicate your preference.)
Email
Home phone
Cell phone
How often would you prefer to connect with your coach?
Daily
Weekly
Biweekly
Which day of the week, Mon-Thurs, is your preferred day for the 30 minute check in call?
Are you available daytime between:
9-11 am
1-3 pm
What does your daily meal schedule look like? Breakfast, Snack, Lunch, Dinner, etc?
What are your trigger foods?
What are your favorite foods?
What are your dislikes?
What is your opinion on leftovers & freezer foods?
Prepping is a key component to being successful. Are you willing to prep?
Yes
No
Which day will be your prep day?
Or will you prep throughout the week?
Throughout the week
Which THM product/ingredients do you have access to?
If you are needing to purchase ingredients from the THM store, my affiliate link can be found here on my website. I receive a small commission at no extra cost to you.
Which THM books do you have access to?
Please note, My coaching is a companion to the THM Plan Book. Because of copyright, you will need your own copy of the THM Plan Book and at least one of the cook books.
Have you read the plan book?
Yes
No
Parts of it
Do you listen to the weekly THM podcast?
Yes
No
Sometimes
Are you a subscriber of the THM membership site?
Yes
No
Subscribing to the Membership Site is not mandatory, but if you’d like a shopping list with your weekly menus, it is. If you choose to subscribe you can save $10 off any subscription with code RY1340
Back
Next
WHICH TYPE OF MAMA DO YOU RELATE TO?
Check the one(s) that BEST describes you:
1. Whole Grain Jane - You grind your own flour, eat mostly whole grains, your diet is high in fruit, dried fruits, and carbohydrates. (Example: banana-based smoothies)
2. Drive Thru Sue - You are constantly on the go, frequent restaurant drive thru’s, do not have time for a lot of cooking (or don’t like to cook) and eat mostly a Standard American Diet.
3. Raw Green Colleen - You juice carrots, apples and the occasional greens. You sprout and dehydrate. Your diet is high in raw foods and vegan or vegetarian-based.
4. Farm Fresh Tess - You eat mostly homemade and farm-raised meat and produce. Your diet also includes starchy carbohydrates like potatoes and pasta but always in whole food form. You are a meat and potatoes type family.
5. Scared of Carbs Barb - You have been on and off low-carb diets for years and you are terrified of adding too many carbs into your diet, even though sometimes you find herself binging on them. Due to this low-carb state, your metabolism has slowed down and shedding weight has become much harder in recent years.
6. Adrenal Splat Pat - You have adrenal issues, stalled weight loss, food sensitivities.
Your fibromyalgia keeps you from exercising.
7. Thyroid Mess Jess - You ate low-carb for a while, continue to put on weight, have low energy, dry skin, and dry hair.
Tell me, HOW ARE YOU BEST SUPPORTED?(Example: Gentle nudging, “hard” pushes, or somewhere in between.)
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform