Client Tracking Sheet

ADVERTISEMENT

Client Tracking Sheet
Client name: __________________________________________________________ ID# ____________________________
Process date: _________________________________________________________
Self-adjust: _____________________
User name: ___________________________________________________________
Password: _____________________
Address: _______________________________________________________________________________________________
City: _________________________________________________ State: _____________
Zip Code: _________________
Best Time: ____________________________________________ Time Zone: _____________________________________
Phone (work): _________________________________________ Phone (home): __________________________________
Email (work): __________________________________________ Email (home): ____________________________________
Occupation: _________________________________________
Hours: _________________________________________
Exercise: _______________________________________________________________________________________________
q
q
q
q
Frequency:
daily
3-5 days/wk
1-2 days/wk
None
Medications:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
q
q
Allergies:
None
Soy
Other:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
How did you hear about Take Shape For Life? ______________________________________________________________
______________________________________________________________________________________________________
WEIGHT-LOSS GOALS
Current Weight: __________________
Height: ________________ BMI: __________________
How much weight would you like to lose? ___________________________ pounds
Why do you want to lose weight?
1. ____________________________________________________________________________________________________
2. ____________________________________________________________________________________________________
3. ____________________________________________________________________________________________________
Which other weight-loss methods have you tried?
Plan/diet
Result
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
For you personally, what is the most difficult thing about losing weight?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
q
q
Is your family aware that you’re starting this program?
Yes
No
On a scale of 1 (not at all) to 10 (very), how motivated do you feel today? ___________________
Do you know of anyone who might want to start this program with you?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2