Mary Keel

Certified Independent Optavia Coach

Let's Connect!

Hey! I'm so excited to talk with you about your health goals!

1) Please fill out this quick health assessment and then schedule a time that's convenient for you to talk

Pick a Date and Time

Mon	Tue	Wed	Thu	Fri	Sat	Sun
30	31	1	2	3	4	5
6	7	8	9	10	11	12
13	14	15	16	17	18	19
20	21	22	23	24	25	26
27	28	29	30	31	1	2

Available Starting times for Sat, Jan 11, 2025

Health Assessment

Mary Keel, Certified Health Coach

Name *

Email *

Address *

City *

State *

Postal code *

Phone *

Birth Date

How did you hear about our program?

____________________________________________________

Awaken... Discover where you are and where you want to be!

Describe where you are in your Health now... (weight, sleep, stress, energy, etc)

Describe where you would like to be in your health...

Please describe WHY you are interested in getting healthy. (What will change after you get healthy, e.g. activities, confidence, being in pictures, etc.)

Who else benefits when you get healthy?

__________________________________________________

Medical

Sex

Male

Female

If Female, Are You Nursing?

Yes

No

If yes, how old is your baby?

Do you have any the following?

Diabetes - Type 1

Diabetes - Type 2

High Blood Pressure

Gout

Are there any food or other allergies that I should be aware of?

Are you taking other medications or have other medical conditions that could influence which program we choose?

*Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor.

**Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication.

***Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.

__________________________________________________

Sleep

How many hours of sleep do you typically get?

Do you wake up feeling rested?

__________________________________________________

HYDRATION

How much water do you drink each day?

How much Alcohol?

__________________________________________________

MOTION

How would you rate your energy level? (on a scale of 1-10)

How many times a week do you exercise?

__________________________________________________

STRESS

How would you rate your stress level? (on a scale of 1-10)

What do you do for work?

How much do you enjoy what you do?

Are there other stressors in your life?

__________________________________________________

EATING HABITS

What does a typical day eating look like?

How many times a week do you eat out?

Where?

__________________________________________________

WEIGHT

Current Weight

Goal Weight

Height

On a scale of 1-10 (10 meaning ready to go!), how motivated are you to start working on your health goals?

What has been most difficult about losing/maintaining weight in the past?

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SURROUNDINGS

How healthy would you rate your surroundings? (on a scale of 1-10)

Do you have healthy & active friends, supportive family, keep junk food in the house, etc?

Is there anyone in your life who would like to get healthy with you?

Their Name