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Health Coach Quality of Life

Client's current payment month

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Currently Taking Anti Obesity Medication?

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Currently Taking Anti Obesity Medication?

A

Yes

B

No

Which Anti Obesity Medication?

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Current Dose

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Number of Months on Medication

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Any Other Weight Loss Medication?

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Energy

On a scale of 1-10, how would you rate your energy level now compared to a month ago?

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On a scale of 1-10, how would you rate your energy level now compared to a month ago?

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10

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Sleep

On a scale of 1-10, how would you rate your sleep quality now compared to a month ago?

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On a scale of 1-10, how would you rate your sleep quality now compared to a month ago?

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Stress

On a scale of 1-10, how would you rate your ability to manage stress now compared to a month ago?

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On a scale of 1-10, how would you rate your ability to manage stress now compared to a month ago?

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10

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Physical Activity

How many times per week do you intentionally do physical activity?

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How many times per week do you intentionally do physical activity?

A

0 times per week

B

Once a week

C

2 times per week

D

3 times per week

E

4 times per week

F

5 or more times a week

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