Thank you for signing up for coaching with an ActiveFlicks Coach. We applaud you for taking one step to transforming your life! The first step is to fill out this form so we can get to know you and customize your program. 

Name
Name
(MM/DD/YYYY)
Illnesses, diseases, injuries, surgeries, etc
Are you taking any medication?
Has your weight fluctuated more than a few pounds?
Have you recently experienced any faintness, light-headedness or blackouts?
Do you often experience trouble sleeping?
Have you recently experienced any blurred vision?
Have you recently had any severe headaches?
Have you felt unusually nervous or anxious for no apparent reason?
Do you experience shortness or loss of breath while walking?
Do you experience sudden tingling, numbness or loss of feeling in your arms, hands, legs, feet or face?
If you don't eat breakfast, put none
If so, how much and on what?
Do you get up during the night to eat?
Do you usually snack while watching TV?
Do you have children?
reading, gardening, crafts, etc.