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We are currently providing virtual appointments in light of the COVID 19 situation.
Click here for updates
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Client Follow-Up
Client Follow Up Form
Please fill out all fields thoroughly so that we can continue to assist in you living your best life!
Name
*
First Name
(MI)
Last Name
Email
*
Phone
*
Age
*
Height
*
Today's Date
*
Your Start Weight (lbs)
*
Current Weight (lbs)
*
Initial Goal Weight (lbs)
*
Current Goal Weight (lbs)
*
How much weight have you lost since your last follow-up? (lbs)
*
How much weight have you lost overall? (lbs)
*
Do you have daily bowel movements (BM)?
*
Yes
No
Do you take anything to have BM?
*
Yes
No
If yes, what do you take for BM?
*
Are you a part of our Facebook group?
*
Yes
No
Are you looking at our Instagram/Facebook pages for the recipes?
*
Yes
No
Do you listen to the “Mastering Your Mind” calls?
*
Yes
No
Are you opening the weekly emails?
*
Yes
No
Are you watching the short videos from Dr. Kells?
*
Yes
No
Are you reading the text messages we send you?
*
Yes
No
Did you have any concerns over the last month?
*
Yes
No
If so, do you still have questions about those concerns?
*
Yes
No
Are you texting/emailing/calling when you have a question, concern, or a celebration to share?
*
Yes
No
On a scale of 0-10, how satisfied are you with your weight loss?
*
(Not satisfied =
0
) (Very satisfied =
10
)
Please enter a number from
0
to
10
.
On a scale of 0-10, how closely have you followed your plan?
*
(Not at all =
0
) (Very thoroughly =
10
)
Please enter a number from
0
to
10
.
On a scale of 0-10, what is your stress level?
*
(Not stressed =
0
) (Very stressed =
10
)
Please enter a number from
0
to
10
.
Are you still weighing and measuring your food?
*
Yes
No
How many cups of veggies are you eating at each meal?
*
How many ounces of water are you drinking per day?
*
What do you struggle with the most?
*
Please
CHECK
the
level of improvement
regarding the following:
» Acid Reflux
*
N/A
Same
Better
Gone
» Thyroid Disease
*
N/A
Same
Better
Gone
» Depression
*
N/A
Same
Better
Gone
» Brain Fog
*
N/A
Same
Better
Gone
» Anxiety
*
N/A
Same
Better
Gone
» Fatigue
*
N/A
Same
Better
Gone
» Diabetes Type I
*
N/A
Same
Better
Gone
» Diabetes Type II
*
N/A
Same
Better
Gone
» High Cholesterol
*
N/A
Same
Better
Gone
» High Blood Pressure
*
N/A
Same
Better
Gone
» Arthritis
*
N/A
Same
Better
Gone
» Headaches
*
N/A
Same
Better
Gone
» Low Libido
*
N/A
Same
Better
Gone
» Sleep Issues
*
N/A
Same
Better
Gone
Have you had any recent medical changes that we should know about (ex. hospitalizations, off C-PAP machine, etc.)?
*
Have you and/or your medical doctor been able to reduce or eliminate any medications?
*
Yes
No
N/A
If so, which ones?
*
Any questions/concerns?
*
What are your successes for this month?
*
Comments
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