Program Forms Halfway Revisit Form

PROGRAM FORMS / HALFWAY REVISIT FORM

Before our scheduled meeting, please fill out and submit the form below. It's best to have this form filled out at least the day before our meeting so I have a chance to review it.

Hurray! You've made it half way! I'm humbly proud of you, as it hasn't all been easy breezy. However, I'm excited for you to fill out the form below. It is a chance for us both to reflect just how far you've come, what has been the most rewarding for you, what could use more focus, and how we will progress forward.

All of your information will remain confidential between you and your Health Coach.

Personal Information

First nameLast nameToday's DateWhat overall positive changes in your health and well-being have you noticed since starting your 6-month program?What goals have been met?Are there areas you would like to focus on, shift, or approach differently in order to meet your goals?What recommendations did you find helpful and which do you continue to use?Please list any people in your life you think could also benefit from work like this.What is your main concern at this time?Have there been any changes in pain, stiffness, or swelling?Have there been any changes in constipation/diarrhea/gas/gastrointestinal issues?Have there been any changes in your cravings or addictions?Any changes with weight?How is your sleep?Please list any supplements or medications you are currently takingWhat types of physical activity are you doing, and how often?

Food Information

List what foods you eat on your MOST healthy day:BreakfastLunchDinnerSnacksLiquidsList what foods you eat on your LEAST healthy day:BreakfastLunchDinnerSnacksLiquidsWhat foods do you crave and when?What percentage of your food is home-cooked?Where do you get the rest from?

Wellness Information

How is your mood?Rate each of the categories below on a scale of 1-10, where 1 is not at all comfortable with where you stand, and 10 is very satisfied with where you are:RelationshipsPhysical ActivityCareerSpiritualityI define “self-care” asList the types of self-care you currently partake inDailyWeeklyMonthlyAny questions about foods or ideas introduced so far?Anything else you would like to share?

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