Halfway Revisit Form

First Name

Last Name

Select a date

What overall positive changes in your health and well-being have you noticed since starting the program?

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 could also benefit from work like this.

What is your main concern at this time?

Any other comments?

Any changes with weight?

How is your sleep?

Constipation or diarrhea?

How is your mood?

Are you exercising?

What foods do you crave and when?

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

Whats your diet like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

Any questions about foods or ideas introduced so far?

What are you looking forward to the most in the next half of the program?

Any other comments?

I CONSENT:In my Intake Forms and assessment forms, I ask for some limited health history from you. I ask these questions because health coaching guidance can be more useful if I know the overall context. In addition, I may want to encourage and advise you to consult with your medical professionals for any disease conditions. I may refer you to various networks of healthcare professionals, and therefore it will be easier if I have a more complete record of your overall wellness. I am only providing coaching guidance— focusing on lifestyle, habits, and goals—and never giving you medical or psychological advice about the underlying condition.

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Halfway Revisit Form

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The Website content is educational and informational in nature and is not medical, psychological, or nutritional advice, opinion, diagnosis, treatment, or guarantee. The information contained herein does not create a professional relationship between you and I.

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- Susan Viola