WELLNESS EVALUATION FORM – September 2008
Thank you for your cooperation in answering the following questions. This information will be held in strict confidence and will be used only to determine what you need and how we can help you.
Name __________________________________________________________
Date ___________________
Home #
____________________ Cell # ___________________ Work # (optional) ____________________
E-Mail/Fax
_____________________________________ Best Times To Be Reached
__________________
What are your reasons for having
a wellness evaluation today? _____________________________________
Do you have any specific health
and wellness goals? _____________________________________________
Height: _____ Weight: ______ Age: _____
BMI: _____ Disease Risk: _______ Protein:
___________
Resting Metabolic Rate _________
Calories for Maintenance/Weight Loss: ________ Water: ________
Breakfast
_____________________________________________________________________ $/day ____
AM Snack
____________________________________________________________________ $/day ____
Lunch
_______________________________________________________________________ $/day ____
PM Snack
____________________________________________________________________ $/day ____
Supper
_______________________________________________________________________ $/day ____
Evening Snack _________________________________________________________________ $/day ____
How much milk? ________ How much water? ________ Are you satisfied after you eat? [_] Yes [_] No
What type of foods do you crave?
____________________________________________________________
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[_]Fatigue [_]Stress [_]Depression
[_]Aches & Pains [_]Indigestion
[_]Diabetes [_]Allergies [_]Headaches
Energy Level 1-10 _____ What time lowest? _________ Any
medications? [_] Yes [_] No
Any dietary restrictions? [_] Yes [_] No If so, what _____________________________________________
Do you use any supplements? [_] Yes [_] No If so what
_________________________________________
Need To Lose (Gain) _________ Are you serious? [_] Yes [_] No
_______________________________________________________________________________________
(Men on average loss 5-8 lbs/month and women loss 3-5 lbs per month)
Office Use: Grams of Protein/Calories a) 2 tbsp or 1 scoop (S.) of MR with 1 ˝ cups (375ml) non-fat milk/Soya Milk 15/210 b) 2 scoops of MR non-fat milk/Soya Milk 18/260 c) 1 S. of MR & ˝ S. of PPP with non-fat milk/Soya milk 20/230 d) 2 scoops MR &1 scoop PPP – 28/300 e) 2 scoops MR & 2 scoops PPP – 38/340 f) Bars 12/150 Drink 15/70 Soup 15/70 Fruit 0/70 Meat (size of palm) 25/140
On average Women
need approx. 100 G.of P. and Men 150 G.of P. with a minimum of 1200-1500
Calories.
[_] Shaker Cup [_] Tablet Box [_] Powder Container [_] Measuring Spoon [_] Tape Measure
[_] Eating Guide [_] Product Catalog [_] DVD/Video/Audio Tapes _______________________________
Other
_______________________________________ Recent Photo ______
ID.#
____________________ Date
______________ H.A.P. #
____________ Discount % ________ Sponsor & ID.#
____________________________________
Payment Information
______________________________________________________________________
Referral Log:
Name, Phone Number and Amount of Credit.
1) ____________________________________
2) _________________________________________ 3) ________________________________________ 4) _________________________________________ 5) ________________________________________
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Date |
Weight |
Upper Chest |
Bust/ Chest |
Arms R / L |
Waist |
Hips |
Thighs R / L |
Weekly Loss/Gain |
% Lost |
Total Pounds |
Total Inches |
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Week 2 |
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Week 3 |
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Week 4 |
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Week 5 |
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Week 6 |
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Week 7 |
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Week 8 |
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Week 9 |
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Week 10 |
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Week 11 |
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Week 12 |
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Week 13 |
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Week 14 |
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Week 15 |
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Product Information: Dates, Products Purchased, $ Amounts,
Volumes, Results,
Start Date______________
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