Weekly Habit Tracking Form - GetReliefRX

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Step 1 of 7 - Information

14%

Your Information

Full Name(Required)

First Last

Phone(Required)

Tracking

How Many Days On Medication?(Required)

Current Weight(Required)

Total Weight Loss To Date(Required)

Which Core Four Habit are you currently focusing on?(Required)

Drinking Water

Increasing Protein

Moving Your Body

Improving Sleep

The Core Four Check-In

On a scale of 1-5, how would you rate your consistency with the following habits this week? (1 = Worst, 2 = Less then expected, 3 = Just ok, 4 = More then expected, 5 + Crushed it)

Hydration (Water Intake)(Required)

worst

1

mid

2

3

better

4

best

5

Protein (Meal Choices)(Required)

worst

1

mid

2

3

better

4

best

5

The Core Four Check-In

On a scale of 1-5, how would you rate your consistency with the following habits this week? (1 = Worst, 2 = Less then expected, 3 = Just ok, 4 = More then expected, 5 + Crushed it)

Movement (Physical Activity)(Required)

worst

1

mid

2

3

better

4

best

5

Sleep (Quantity & Quality)(Required)

worst

1

mid

2

3

better

4

best

5

Let's Go Deeper

Energy Levels(Required)

1 = Worst

2 = Less then Expected

3 = Just Ok

4 = More then Expected

5 = Crushed It

Mood & Motivation(Required)

1 = Worst

2 = Less then Expected

3 = Just Ok

4 = More then Expected

5 = Crushed It

Weekly Wins / Challenges

What was a highlight or win this week - big or small?

Did you run into struggles, frustrations, or challenges this week?

Optional Notes for Your Coach

Anything else you'd like to share or ask your coach about?

WEEKLY

Habit Tracking

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