Goal Support

 
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Your CURRENT HEALTH and Interests

You joined the 10-Week Transformation Challenge to ultimately achieve something specific. Fantastic!

To be prepared for day one and the next 10-weeks of the Transformation Challenge we ask you to complete this Initial Assessment & Triage. This will help Coach Anita understand your current lifestyle and your habits, plus prepare her to help you set your 10-week goal at the time of your pre-measurement.

Please submit honest answers to the following questions, self-rating, and short descriptions.

Name *
Name
Phone *
Phone
How do you prefer Coach Anita to contact you? *
In general, what are your goals? *
Have you tried anything in the past to change your habits, your health, your eating, and/or your body? *
Have you already made changes to your habits, your health, your eating, and/or your body recently? *
Right now, how would you rank your overall eating/nutrition habits? *
Are you regularly active in sports and/or exercise? *
If so, approximately how many hours per week?
Approximately how many hours a week do you do other types of physical activity? (e.g. housework, walking to work/school, home repairs, moving around at work, gardening) *
Who lives with you? Check all that apply.
Do you have children?
Who does most of the grocery shopping in your household? Check all that apply. *
Who does most of the cooking in your household? Check all that apply. *
Who decides on most of the menus/meal types in your household? Check all that apply. *
Right now, how much do the people and things around you support health, fitness, and/or behavior change? *
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries? *
Right now, do you have any specific health concerns, such as illnesses, pain, and/or injuries? *
Right now, are you taking any medications, either over-the-counter or prescription? *
On a scale of 1-10, how would you rank your health right now? *
HOW ARE YOU SPENDING YOUR TIME?
In an average week, how many hours do you spend in...
On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness? *
HOW IS YOUR STRESS AND RECOVERY?
Think about all the activities you're involved in (e.g. work, school, housework, travel). Then assess as best you can:
Given all the demands of your life, what is your typical stress level on an average day? *
On average, how many hours per night do you sleep? *
HOW READY, WILLING, AND ABLE ARE YOU TO CHANGE?
Right now, on a scale of 1-10:
How READY are you to change your behaviors and habits? *
How WILLING are you to change your behaviors and habits? *
How ABLE are you to change your behaviors and habits? *
DISCLAIMER
Please recognize that is your responsibility to work directly with your health care provider before, during, and after seeking health consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.
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