Eat to Thrive Registration Form

This form is interactive. Some additional questions and sections will open as you fill in the form. It is important that you put something in every field that is marked with a red asterisk. (*) Please take your time and answer each question completely.

Full Name*

Email*

Enter Email Confirm Email

Track Option*

New Student
Repeat Student
Health Educator Certificate

When did you last take the class?*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number*

This is the phone number you'd prefer we use to contact you.

About the phone*

Phone Is A Landline - I do not own a cell
Phone Is A Landline - I also have a cell phone
Phone Is a cell phone

Cell Phone*

Class Introduction

To introduce yourself to class members on the first day of class and to help me to assist you in meeting your objectives, please fill in the following which you can use as a class introduction. This should be no more than 2 minutes when you read it. This is very important and a requirement for the graduation certificate Each time you take the class you will be developing another new habit and achieving new objectives to achieve optimum health. Please fill in this entire section before you move on to the rest of the form.

Name*

Career*

Family Life*

My 3 objectives for taking the Eat to Thrive course are:

Objective 1*

Objective 2*

Objective 3*

The number one habit to develop in this 10-week program is:*

Details About You

Date of Birth*

Marital Status

Married
Single

Sex

Male
Female

Names and Ages of Your Children

Occupation

How many years at your job

Emergency Contact Name*

Relationship of Emergency Contact*

Emergency Contact Phone Evening*

Emergency Contact Phone Day*

About Your Habits

Where did you learn about this course?*

How long have you been interested in the subject of nutritional health?

Supportive Friends*

Do you have a network of friends who are currently supporting you in pursuing a healthy lifestyle?

Family Support*

Does your family support you in pursuing a healthy lifestyle? Who lives in the same household with you and what is their relationship to you (mother, father, husband, daughter and son please list ages)

Have you ever worked with a personal trainer before?*

Yes
No

Do you participate in a regular exercise program at this time?*

Yes
No

About your exercise program - check all that apply*

Stretching
Weight Lifting
Aerobic Excercise
Resistance Training
Belong to a gym

Walking*

Can you currently walk 4 miles briskly without fatigue?

Yes
No

About Stretching*

How many times a week do you stretch and for how many minutes each time?

About Weight Lifting*

How many times do you weight lift each week and for how many minutes each time?

About Aerobics*

About your aerobic exercise: How many times per week and for how long each time?

Injuries

Describe any injuries or disabilities that may interfere with exercising.

Smoking History

If you smoke or have smoked in the past please describe how much per day, at what age you started and if you quit, when did you quit. Also describe the modalities you used.

Your Diet*

What kind of diet do you practice regularly? (Do not check vegan if you occasionally consume meat, fish or dairy products).

Standard diet including meat, fish, dairy
Lacto Ovo Vegetarian (including eggs)
Vegan (Raw & Cooked Vegetable and Fruit only
Natural Hygiene (Vegan using only raw foods)
Living Foods (Vegan with at least 25% Sprouts)

What percent of your diet is vegetable?*

What percentage of your daily intake is cooked?*

Meditiaion/Stress Reduction

Share what you have as a practice of inward reflection or meditation or stress reduction if you have one.

Study & Research

List any special areas of study or research

Your Strengths*

Please list 12 of your strengths

Language

List any languages that you speak other than English.

Hobbies & Skills

List any special skills and hobbies.

Education

Name and Location of School, # of years attended, graduated major field of study.

Learning Style*

Explain how you learn and share any other concerns related to learning you might have. If you have none write in "none".

Kitchen Equipment*

What kitchen equipment (blender; juicer, food processor, dehydrator ) do you own and what brand?

To show your progress scientifically through practicing the Hippocrates approach, blood tests are essential. Please obtain a copy of your recent blood test or have one taken before and after the class. This information will be kept strictly confidential.

Medical History

My overall heath is:*

Excellent
Fair
Poor

List current medical issues:

If you are seeking medical attention or currently under a doctor's care please list reasons here

Psychiatric Care

If you are currently seeking psychiatric care or under the care of a psychologist, please list the reason why

Medications

Please list any medications you are taking including dosage and reasons for use.

Depression, Fatigue or Exhaustion

Have you experienced in the past year or are you currently experiencing any fatigue, depression or exhaustion? List the reasons and details here.

Check all that apply

Operations and Other*

Do you want to lose weight?*

Yes
No

Weight Lost Section

This is a great option for tracking progress because it doesn't require any fancy equipment and anyone can do it. Taking your measurements in certain areas can give you an idea of where you're losing fat, which is important since we all lose fat in different areas of our body and in a different order.

Weight Today

Height Today

Taking your measurements can help reassure you that things are happening—even if you're not losing fat exactly where you want just yet.
Start measuring by wearing tight-fitting clothing (or no clothing) and make a note of what you're wearing so you know to wear the same clothes the next time you measure.
Here's how to do it:

Bust

Measure around the chest right at the nipple line, but don't pull the tape too tight.

Chest

Measure just under your bust.

Waist

Measure a half-inch above your belly button or at the smallest part of your waist.

Hips

Place tape measure around the biggest part of your hips.

Calves

Measure around the largest part of each calf.

Thighs

Measure around the biggest part of each thigh.

Upper Arm

Measure around the largest part of each arm above the elbow.

Forearm

Measure around the largest part of the arm below the elbow

Write down all your measurements prior to the start of class and keep track of your progress.
It may seem obvious, but don't overlook one of the simplest ways to track progress—how your clothes fit.
Take a picture of yourself wearing a bathing suit or workout pants and for women, a sports bra and save it in the Eat to Thrive folder. Take another picture at the end of your 10 week Eat to Thrive workout.
You can also use your clothes to keep track of your progress. Choose one pair of pants that are a little tight and try them on every four weeks to see how they fit. Make a note of where they feel loose, where they feel tight, and how you feel wearing them. Keep one set of clothing for comparison a month from now.
Whatever the scale says, your pants will never lie