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This form is to be filled out and submitted by current clients only!
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NAME
*
First
Last
Entry is for what DAY & DATE:
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EMAIL
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Rate your Level
(*all entries required)
How many hours of sleep did you get last night?
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Quality of sleep? (1) = poor to (10) = high/ great
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Stress? (1) = low to (10) = very high
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Energy? (1) = low to (10) = high/ great
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Mood? (1) = low/bad to (10) = high/great
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Fitness
(optional entry)
Walk, Run, Cycle, Eliptical or Cardio Class: Type & Mins.?
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Steps?
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Miles?
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Weights or Strength Training Class: Minutes?
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Pilates: Minutes?
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Yoga: Minutes?
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Sport/ Other: Type & Mins.?
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Hydration
(*all entries required)
Water: How many 8 oz. servings?
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Tea: How many 8 oz. servings?
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Coffee: How many 6 oz. servings? (TALL latte is 12 oz.)
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Other, if applicable
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You may complete the Food Log or the Food Journal or Both
Food Log
(optional entry)
Protein: How many palm-sized servings?
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Vegetables, non-starchy veggies: How many fist-sized servings?
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Fruits: How many fist-sized servings?
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Grains/ Starchy Veggies: How many fist-sized or cupped-hand-sized servings?
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How many full-thumb-sized servings?
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How many indulgences (fried, high-fat, sweets, soda, alcohol, etc.)?
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Any cravings? My response to Cravings?
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Multivitamin/ Supplements taken? Yes or No
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Females
(General guidelines for Servings)
Males
(General guidelines for Servings)
Food Journal
(optional entry)
BREAKFAST: When, where, what did you eat?
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LUNCH: When, where, what did you eat?
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DINNER: When, where, what did you eat?
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SNACKS: What did you eat?
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Any cravings? My response to cravings?
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Reflection
(optional entry)
Positive Thing(s) that happened today?
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What, if anything, can I do to make tomorrow better?
*
Submit
Home
WELLNESS PROGRAMS
Digital Wellness
Education & Coaching
>
Better Habits Coaching
Prevent T2 Diabetes
Smoking Cessation Clinic
Asthma Self-Management
Physical Activity
>
Movement Lab Classes
Private Fitness Training
CPR & First Aid Training
Well at Work
FAQ
Insurance Q&A
Blog
Health Professionals
About Us
Who We Are
Feedback Form
Contact Us
ACCOUNT LOGIN