New Patient Enrollment - Bettrmyhealth

New Patient Enrollment Form

Well done, you’ve taken the first step towards transforming into a bettr you. Kindly fill out this simple form because the better we know you, the better we’ll heal you!

Let’s begin by getting to know each other! Hi 👋, I’m your Personal Health Coach, and you are?

Hi, My Name Is *

My Age is *

You can email me at *

You can call me on *

I currently weigh *

My Height is

Ft *

in *

My gender is *MaleFemaleOther

Where do you need the most attention?BellyButtBreast/ ChestLegsArms & ShouldersBack

Good to meet you {name-1}! Now please tell me about your food and water intake! Just answer these simple questions.

What is your dietary food preference? *VegetarianNon-VegetarianEggetarian

How much water do you drink daily? *

How many meals do you eat in a day? *

What do you usually have for your breakfast, and around what time? *

What do you usually have for your lunch, and around what time? *

What do you usually have during your snack time, and around what time? *

What do you usually have for your dinner, and around what time? *

Is there anything I missed out on, like extra meals, or dairy intake? Please use this space to speak your heart out!

Great {name-1}, Now I know about your eating habits. Let’s have a conversation about your sleeping habits.

Health Tip: Sleep is as important for good health as diet and exercise.

I usually wake up at

and sleep at

Okay! So on average how much sleep do you get? *Less than 5 hours5-6 hours7-8 hoursMore than 8 hours

How often do you have trouble sleeping?Every nightA couple of nights a weekEvery now and thenRarely or Never

How do you feel after waking up?Refreshed and ready to conquer the dayMore often OK than notDon't talk to me until I've had my coffee or teaLow, I don't feel like waking up

How energetic are you during the day?High and mightyDragging before mealsPost lunch slumpLow, I feel tired throughout the day

I’m impressed by the dedication you’re showing to transform your life! You’re doing great {name-1}! Now comes a very crucial step in deciding your health plan. Fill out the form below!

Are you taking any medications? If YES, please write in the space below in this

MEDICINE NAME

Time

Do you have any medical conditions? If YES, please speak your heart out!

You’re almost there {name-1}! Now, let’s see how active are you!

How often do you exercise?Almost everyday3-4 times per week1- 2 times a weekMore like once a monthNever

How often do you walk?Almost everyday3-4 times per week1- 2 times a weekMore like once a monthNever

Choose up to 3 activities you’re interested in.Fitness at homeGymRunningWalkingYogaHIIT (High-Intensity Interval Training)Other

One more thing! Bettr My Health wants you to be comfortable with your personal health coach. Let them know so they connect you with the right one!

How would you describe your ideal health coach? *Highly EnergeticKnows when to give me tough loveCalm-mindedAlways PositiveDrill instructorAnalytical and result-orientedStrictly means businessGoes the extra mile to personalize my plan

Anything else you want to talk about?

How did you come to know about us? *