Weight Loss Focus Reflection on Life and Change Your DetailsFirst Name*Surname*Date of Birth* Date Format: MM slash DD slash YYYYSex*MaleFemaleOccupationAddressEmail* Phone Number (including country code)* General Questions1. What problem are you trying to solve?*(include your current weight and weight goal)2. How do you sleep?*(Describe including hours)3. How would you describe your mental health and or mindset?*(ie are you in a stressed workplace or mindset)4. Do you have a good bowel movement every day? ( not constipated or the lose movements) [Yes or No]*YesNo5. How often do you drink alcohol?*AbstainRarely (1 or 2 glasses a month)Sometimes (1 or 2 glasses a week)Moderate (1 or 2 glasses several nights a week)Often (I need a wine or beer to relax most nights)I have a drinking problem6. Do you eat your food at your desk while doing emails or in busy meetings or in a relaxed state?*at desk while doing emailsin busy meetingsin a relaxed stateAllOther (If Other, please specify.)Other (Please specify)*7. Do you drink milk? (please explain)*8. How often do you eat bread, Pasta, Rice, Cereals?*9. Do you exercise? (Yes or No)*YesNo10. Exercise activity per week*1x per week2x per week3x per week4x+ per week11. Type of Exercise*JoggingBoxingHIITOther12. How important is it to you to hit your weight goals? (1-10, 10 is best important)*1234567891013. Do you work for yourself?*14. Do you enjoy you work?*15. Do you have any medical conditions?*16. Are you on any medications?*17. Where do you see yourself in 6 months from now with your health?*18. What is important to you in your life?*19. Have you ever used a coach before?*20. Are you a member of a gym or health club?*21. What are your hobbies?*22. What if anything worries you?*23. Do you regularly see a Doctor?*24. Describe what you do for exercise*25. How important is it that you achieved your goals? (1-10, 10 is best important)*12345678910EmailThis field is for validation purposes and should be left unchanged.