Sustainable | Healthy | Living - Halfway Revisit Form

Health History Forms

Halfway Revisit Form

Name

First Name

Last Name

Date

YYYY

What overall positive changes in your health and wellbeing have you noticed since starting your program with Sonali?

What goals have been met?

Are there areas you would like to focus on, shift, or approach differently in order to meet your goals?

What recommendations did you find helpful and which do you continue to use?

Please list any people in your life you think would also benefit from work like this:

What is your main concern at this time?

Any changes with weight? Please explain:

How is your sleep? Please explain:

Are your experiencing any constipation or diarrhea?

How is your mood? Please explain:

Are your exercising? If so, how often?

What foods do you crave and when?

What percentage of your foods do you cook/prepare at home?

What is your current diet like?

Breakfast, Lunch, Dinner, Snack, Liquids

Any other comments?