Lost at ASHA - 2011 Weight Loss Program Lost at ASHA - 2011 Weight Loss Program

Individual Intake Card Individual Intake Card

NAME: NAME:
12-week weight loss goal (in lbs): 12-week weight loss goal (in lbs):
Willing to be team captain: YES NO Willing to be team captain: YES NO
Select up to 3 challenges to losing weight: Select up to 3 challenges to losing weight:
Family commitments Time to workout Family commitments Time to workout
Lack of motivation Trigger foods Lack of motivation Trigger foods
Maintaining motivation Lack of energy Maintaining motivation Lack of energy
Time to plan healthy meals Money Time to plan healthy meals Money
Hard to get/stay on track Snacking Hard to get/stay on track Snacking
Sabotage from family/friends Sabotage from family/friends
Other – Other –
Three (3) habits you want to change: Three (3) habits you want to change:
1. 1.
2. 2.
3. 3.
Top 3 foods you can’t live without: Top 3 foods you can’t live without:
1. 1.
2. 2.
3. 3.
(Opt.) Preferred team members: (Opt.) Preferred team members:

Lost at ASHA - 2011 Weight Loss Program Lost at ASHA - 2011 Weight Loss Program
Individual Intake Card Individual Intake Card
NAME: NAME:
12-week weight loss goal (in lbs): 12-week weight loss goal (in lbs):
Willing to be team captain: YES NO Willing to be team captain: YES NO
Select up to 3 challenges to losing weight: Select up to 3 challenges to losing weight:
Family commitments Time to workout Family commitments Time to workout
Lack of motivation Trigger foods Lack of motivation Trigger foods
Maintaining motivation Lack of energy Maintaining motivation Lack of energy
Time to plan healthy meals Money Time to plan healthy meals Money
Hard to get/stay on track Snacking Hard to get/stay on track Snacking
Sabotage from family/friends Sabotage from family/friends
Other – Other –
Three (3) habits you want to change: Three (3) habits you want to change:
1. 1.
2. 2.
3. 3.
Top 3 foods you can’t live without: Top 3 foods you can’t live without:
1. 1.
2. 2.
3. 3.
(Opt.) Preferred team members: (Opt.) Preferred team members: