Accountability Form – Rene Petropolis

To be completed one day prior to your check-in call

If you have questions, please email me directly: rene@copperstatefit.com

NAME (FIRST AND LAST)(required)

EMAIL(required)

DATE OF CHECK IN CALL(required)

ENERGY(required)

HUNGER(required)

MOOD(required)

STRESS(required)

SLEEP(required)

START DATE OF LAST MENSTRUAL CYCLE (or N/A)(required)

DAILY STEP COUNT(required)

HYDRATION(required)

NUMBER OF MEALS MADE/ CONSUMED OUT OF THE HOME(required)

ALCOHOL CONSUMED(required)

NUTRITIONAL PLAN ADHERENCE(required)

EXERCISE PLAN ADHERENCE(required)

OVERALL SELF ASSESSMENT SCORE(required)

WHICH HABITS ARE YOU MOST PROUD OF THIS WEEK AND WHY?(required)

WHICH HABITS DID YOU FALL SHORT THIS WEEK AND WHY? (required)

WHICH AREAS DO YOU NEED HELP BUILDING MORE CONFIDENCE?(required)

ANY ADDITIONAL WINS YOU'D LIKE TO SHARE?(required)

WHAT HABITS WILL YOU COMMIT TO IMPROVE IN THE NEXT WEEK?(required)

WHAT BARRIERS/ OBSTACLES DO YOU FORESEE IN THE NEXT WEEK? (required)

ANY ADDITIONAL QUESTIONS/ COMMENTS FOR YOUR COACH?(required)