Daily Check In Form Survey

The only way coaching will work, is if you are honest with me and yourself…

The best time to fill this form out is before you go to bed for the night.
The Daily Check In Form needs to be filled out every day for the next 90 days.
You can find the link on the Give Obesity The Boot website
Under One on One Coaching (on the menu bar)
Under Client Forms is the “Daily Check In” link.

*
Name / Date

Name / Date

Sleeping

Sleeping What time did you go to bed?
What time did you get up this morning?

How much water did you drink today? 64 oz. recommended

Did you eat your recommended meat / protein for today? For most of our clients it is between 5 to 6 oz a day.

(EXAMPLES) Meat, Beans, Seeds, Nuts, Eggs, Peanut Butter
1/2 cup of beans, peas, lentils or legumes

1/2 cup English Peas
2 ounces of chicken breast
2 ounces of lean steak
1 egg

The recommended daily protein requirements are derived from "ideal body weight". The ideal body weight is calculated based on height and varies slightly for men and women. Our protein requirements can also be expressed in terms of total caloric intake. The world health organization and many national health agencies have independently conducted studies, which (even though they differ slightly) all conclude our daily protein requirement should be between 10% to 15% of our daily caloric intake.

Did you eat your recommended meat / protein for today? For most of our clients it is between 5 to 6 oz a day. (EXAMPLES) Meat, Beans, Seeds, Nuts, Eggs, Peanut Butter 1/2 cup of beans, peas, lentils or legumes 1/2 cup English Peas 2 ounces of chicken breast 2 ounces of lean steak 1 egg The recommended daily protein requirements are derived from "ideal body weight". The ideal body weight is calculated based on height and varies slightly for men and women. Our protein requirements can also be expressed in terms of total caloric intake. The world health organization and many national health agencies have independently conducted studies, which (even though they differ slightly) all conclude our daily protein requirement should be between 10% to 15% of our daily caloric intake. Yes

Did you have your recommended daily amount of milk / dairy?
For most of our clients it's 2 1/2 - 3 cups a day.

(EXAMPLES) white skim milk

Did you have your recommended daily amount of milk / dairy? For most of our clients it's 2 1/2 - 3 cups a day. (EXAMPLES) white skim milk Yes

Did you eat the recommended total daily amounts of fruits and vegetables today?
You should be eating at least five portions of fruit and vegetables every day!
WOMEN 4 -5 and MEN 4 1/2 - 5 cups a day.

(EXAMPLES)
1/2 cup of dark green vegetables
1 cup of raw green leafy vegetables**
1/2 cup of yellow vegetables
1/2 cup of orange vegetables
1/2 cup of white vegetables
1/2 cup of mixed vegetables
1/2 cup yellow fruit
1/2 cup of green fruit
1/2 cup of orange fruit
1/2 cup of mixed fruit

Did you eat the recommended total daily amounts of fruits and vegetables today? You should be eating at least five portions of fruit and vegetables every day! WOMEN 4 -5 and MEN 4 1/2 - 5 cups a day. (EXAMPLES) 1/2 cup of dark green vegetables 1 cup of raw green leafy vegetables** 1/2 cup of yellow vegetables 1/2 cup of orange vegetables 1/2 cup of white vegetables 1/2 cup of mixed vegetables 1/2 cup yellow fruit 1/2 cup of green fruit 1/2 cup of orange fruit 1/2 cup of mixed fruit Yes

Did you have your recommended daily amount of grains?
For most of our clients it is 7 - 6 ounces a day.
(EXAMPLES)
1 cup of cooked wheat pasta (tan)
3 slices of whole grain bread (tan)
1/2 cup of cereal (multi-color)
1 White Flour Tortilla

Did you have your recommended daily amount of grains? For most of our clients it is 7 - 6 ounces a day. (EXAMPLES) 1 cup of cooked wheat pasta (tan) 3 slices of whole grain bread (tan) 1/2 cup of cereal (multi-color) 1 White Flour Tortilla Yes

What and how much did you have for breakfast? The time was?

What and how much did you have for lunch? The time was?

What and how much did you have for dinner? The time was?

Did you eat dinner with your family at the table?

Did you eat dinner with your family at the table? Yes

What and how much did you have for snacks today? Times?

List all the unhealthy foods (how much) you had today.

List all the health foods you ate today.

How are you feeling today?

Did you have your recommended exercise today?
For most of our clients it is 30 to 45 minutes a day.

Did you have your recommended exercise today? For most of our clients it is 30 to 45 minutes a day. Yes

Who did you exercise with today?

Who did you exercise with today? Alone

With a friend

With family

What type of exercise did you get today and how much?

Have your levels of medications changed?

Have your levels of medications changed? Yes	No	N/A
If yes please explain

Have any of your health conditions changed?

Have any of your health conditions changed? Yes	No	N/A
If yes, please explain.

How are you and your family handling the healthy changes?

What change did you make or comment about today would you like to share?
Tell me if you were happy, sad, mad, ect...

What change did you make or comment about today would you like to share? Tell me if you were happy, sad, mad, ect...

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