Health Questionnaire | Fosters Lifestyle

Name

First Last

Date

Phone

Email

How did you hear about the Balanced Habits KICK START?*

What is your MAIN GOAL by participating in the KICK START?*

How many MEALS do you currently consume on average per day?*

How many SNACKS do you currently consume on average per day?*

How often do you do cardiovascular exercise per week?

What is the duration?*

How often do you do strength train per week?*

What is the duration?*

Do you do any other forms of exercise?*

Yes
No

If yes, what?

Are you currently under the care of a Physician?*

Yes
No

If yes, why?

Are you currently taking any medications?*

Yes
No

If yes, please list them and how long you have been taking them:

Have you been diagnosed as Diabetic?*

Yes
No

If yes, what type:

Pre-diabetic
Type I
Type II

If yes, what medications and frequency do you take:

Have you had any form of Bariatric Surgery?*

Yes
No

If yes, what type:

If yes, when was the surgery performed?

If yes, approximately how many ounces of food can you ingest per sitting?

Have you ever dealt with an eating disorder that we should be made aware of?*

Yes
No

If yes, please explain:

Are you currently lactating?*

Yes
No

If yes, on average how many times per day?

Are you a Vegan?*

Yes
No

Do you have Celiac Disease or a high Gluten Sensitivity?*

Yes
No

Your Measurments

Please be sure you watch the below video on how to accurately take your measurements.

Age*

Gender*

Height*

Weight*

Abdomen*

Hip (women only)

Wrist (men only)

Upper R / L Arm*

Upper R / L Leg*

R / L Calf*

Upload your images

Drop files here or

Upload up to 3 images of yourself. Photos will not be shared (unless given permission). It is highly recommended to submit photos though as your final report will have Pre & Post KICK START photos!

Needed photos: Full front view & both side views

Suggestions for the photos:

- Wear clothing that reveals the body contour. Women can wear sports bra/tank top & shorts/leggings and men can wear no top/tank top & shorts.

- Take in a well-lit area, preferably with more natural light

Is there anything you'd like to disclose that we need to know to support you to be successful during the 28-Day program that we have not asked?

Agreement*

Select All
Yes, I have disclosed all necessary information that the Balanced Habits KICK START Team needs to know about me.
Yes, I understand what is expected of me during this 28-Day program and commit to the suggestions and guidelines.
Yes, I will attend the weekly journal review, follow the journal requirements, do the suggested amount of exercise.
Yes, I will read the emails coming from my Food Coach
I promise to not expect perfection, but I do expect improvement due to my efforts.

Name*

First Last

Comments

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