Robin Morton, Certified Health Coach

your health profile: tell me about you

Congratulations on your curiosity in the program and concern for your health. You have come to the right place. Please continue and take just a minute to complete this form. It will be your first step on the path to a healthier life.

Your responses to this questionnaire are confidential and will not be shared with anyone else. After I review your responses, I'll be contacting you. Usually within about 24 hours. If you're ready to start the program (or have questions) and would prefer to speak to me, that's o.k. too. Please call (503) 689-6213.

First Name:

Last Name:

Email Address (required):

Phone:

I prefer to be contacted by:

email     phone

Your Current Height:

 

Your Current Weight:

Age:

Sex:

male   female

Are you currently taking
any medication:

yes     no

Do you have any allergies:

yes     no

Have you been diagnosed
with Diabetes:

yes     no

Do you have
high blood pressure:

yes     no

Do you have
high cholesterol:

yes     no

Do you have other
health-related conditions:

yes     no

Have you tried other
weight-loss programs:

yes     no

What is your target weight:

What is your #1 reason
for wanting to lose weight:

On a scale of 1-10,
how motivated are you:

 (be honest)

if referred by someone,
please list their name
(they will receive a referral credit)

yes     no

Comments:

 

  

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This program offers a fast, safe and affordable way to lose weight fast and keep it off for life. This program is doctor recommended but not intended to take the place of the medical advice from a trained medical professional. Consult your physician before beginning a weight loss program. An independent or Certified Health Coach is not a substitute for a physician or qualified medical practitioner.