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S.T.E.P.S. Program® Coaching Application

Are you at least 30 pounds overweight and at a turning point in your life?

Are you fed up with the overwhelming heaviness, the debilitating fatigue, and the low self-esteem? Are you ready - finally - to reset your female metabolism so you can have more energy than ever before and stop cravings for good? For over twenty years, Miriam has shown women how to do just that - easily, quickly, and naturally. 

Miriam is an internationally recognized weight-loss expert who specializes in rapid results!

She offers private and group coaching programs for women around the world at every stage of life. All programs are structured around her groundbreaking signature system: The S.T.E.P.S. Program® for Permanent Weight-Loss.

Please take your time filling out this confidential application. The more complete your answers, the better Miriam can get to know you. (Information is kept strictly confidential.) To expedite the application process, we ask that you email any recent lab records to support@kosherforlife.com.

Once we've received your application and lab records, a staff member will contact you to set up a complimentary no-obligation call with Miriam. 

During this call, both you and Miriam will decide whether the S.T.E.P.S. Program® is right for you and whether Miriam is the right coach for you. She will be honest with you about whether the S.T.E.P.S. can help you. If not, she will be glad to refer you to practitioners in other modalities that may be better suited to your needs.

If you both feel that the S.T.E.P.S. can help you, Miriam's assistant will prepare your enrollment packet and your test kits will be mailed to you.

Please note: Submitting this application does not guarantee acceptance into the program. 

Serious and appropriate inquiries only.

 

Today's Date Email Daytime Phone

Full Name Date of Birth
 

How did you hear about Miriam?   

Street Address (no P.O. Box, please)

City/Town State Zip Country

Occupation Age Gender Number of Children

Marital Status: Single Partner Married Separated Divorced Widow

Annual Household Income: $0 to $49,999 $50,000 to $99,999 $100,000 to $149,999 $150,000+

Are you pregnant?Breastfeeding?Your weight todayYour height

Have you given birth in the last three months?

Do you get frequent colds or flus?

List any current health problems for which you are being treated:


Current medications (prescription or over-the-counter):


Major hospitalizations or surgeries (including dental): Please list all procedures, complications (if any) and dates:


Check the level of stress you are experiencing on a scale of 1 to10 (1 being the lowest):
1 2 3 4 5 6 7 8 9 10

Identify the major causes of stress (e.g., work, large family, newborn baby, changes in job, residence or finances, legal problems):

Is your lifestyle associated with potentially harmful chemicals (e.g., cleaning products, pesticides, radioactivity, solvents)?


I have: Corrective Lenses Dentures Hearing aid(s) Medical devices/prosthetic/implants


Recent changes in your ability to: see hear taste smell feel hot/cold sensations move around (sit upright, stand, walk, run, pick things up, swing your arms freely, turn your head, wiggle fingers)

Strong like for any of the following flavors: sour bitter sweet rich/fatty spicy/pungent salty

Strong dislike for any of the following flavors: sour bitter sweet rich/fatty spicy/pungent salty

Do you: Prefer warmth (i.e., food, drinks, weather, etc.) Prefer cold (i.e., food, drinks, weather, etc.) No preference
After exercise, do you: Feel better (i.e., refreshed, energized, etc.) Feel worse (i.e., worn out, lethargic, etc.) No different
 

Sleep:

Bedtime (average) Wake up (average) Average hours slept each night

How many times do you wake up each night How long does it take you to fall asleep?

Do you need and alarm to wake up? Yes NoIs your bedroom completely dark? Yes No Are you wide awake at bedtime? Yes No
Do you wake up feeling fatigued? Yes No Do you need coffee to get going in the morning? Yes No  Do you wake up in the middle of the night and find it difficult to get back to sleep? Yes No
 

Do you experience any of these general symptoms EVERY DAY?

Debilitating fatigue
Depression
Disinterest in sex
Disinterest in eating
Shortness of breath
Panic attacks
Headaches
Dizziness
Insomnia
Nausea
Vomiting
Depression
Diarrhea
Constipation
Fecal incontinence
Urinary incontinence
Low grade fever
Chronic pain/inflammation
Discharge
Itching/rash
Bloating
Gas
Acid Reflux


 
 

Medical History

Arthritis
Allergies/hay fever
Asthma
Alcoholism
Alzheimer's disease
Autoimmune disease
Blood pressure problems
Bronchitis
Cancer
Chronic fatigue syndrome
Carpal tunnel syndrome
Cholesterol, elevated
Circulatory problems
Colitis
Dental problems
Depression
Diabetes
Digestive problems
Diverticular disease
Drug addiction
Eating disorder
Epilepsy
Emphysema
Eyes, ears, nose, throat problems
Environmental sensitivities
Fibromyalgia
Food intolerance
Gastroesophageal reflux disease
Genetic disorder
Glaucoma
Gout
Heart disease
Infection, chronic
Inflammatory bowel disease
Irritable bowel syndrome
Kidney or bladder disease
Learning disabilities
Liver or gallbladder disease
(stones)
Mental illness
Mental retardation
Migraine headaches
Neurological problems
(Parkinson's, paralysis)
Sinus problems
Stroke
Thyroid trouble
Obesity
Osteoporosis
Pneumonia
Sexually transmitted disease
Seasonal affective disorder
Skin problems
Tuberculosis
Ulcer
Urinary tract infection
Varicose veins
Menstrual irregularities
Endometriosis
Infertility
Fibrocystic breasts
Fibroids/ovarian cysts
Premenstrual syndrome (PMS)
Breast cancer
Pelvic inflammatory disease
Vaginal infections
Decreased sex drive
Sexually transmitted disease
Other:

Medical History (cont.)

Age of first period
Date of last gynecological exam
Mammogram + -
PAP + -
Form of birth control
# of children
# of pregnancies
C-section
Hysterectomy
Menopause
Date of last menstrual cycle
Length of cycle (days)
Interval of time between cycles (days)
Any recent changes in normal menstrual flow (e.g., heavier, large clots, scanty)

Family Health History (Parents & Siblings)

Arthritis
Asthma
Alcoholism
Alzheimer's disease
Cancer
Depression
Diabetes
Drug addiction
Eating disorder
Genetic disorder
Glaucoma
Heart disease
Infertility
Learning disabilities
Mental illness
Mental retardation
Migraine headaches
Neurological Disorders (Parkinson's, paralysis)
Obesity
Osteoporosis
Stroke
Suicide
Other:

Health Habits

Tobacco:
Cigarettes: #/day
Alcohol:
WIne: #glasses/d or wk
Liquor: #ounces/d or wk
Beer: #glasses/d or wk
Caffeine:
Coffee: # oz cups/d
Tea: # oz cups/d
Soda w/sugar: #cans/d
Diet Soda: #cans/d
Other sources:
Water: #glasses/d

Excercise

5-7 days per week
3-4 days per week
1-2 days per week
45 minutes or more duration per workout
30-45 minutes duration per workout
Less than 30 minutes
Walk
Aerobics
Weight lift
Swim
Tennis
Yoga
Other:
 

Nutrition & Diet

Mixed food diet (animals & vegetable sources)
Vegetarian
Vegan
Salt restriction
Fat restriction
Starch/carbohydrate restriction
The Zone Diet
The Paleo Diet
The Raw Food Diet
The Macrobiotic Diet

Other:

Specific Food Restrictions:
dairy wheat eggs
soy corn all gluten

Other:
 

Food Servings

Servings per day:
Fruits (citrus, melons, etc.)
Dark green or deep yellow/orange vegetables
Grains (unprocessed)
Beans, peas, legumes
Dairy, eggs
Meat, poultry, fish
 

Eating Habits

Skip breakfast
Two meals/day
One meal/day
Graze (small frequent meals)
Food rotation
Eat constantly whether hungry or not
Generally eat on the run
Add salt to food
 

Current Supplements

Would you like to:

Have more energy
Be stronger
Have more endurance
Increase your libido
Be thinner
Be more muscular
Improve your complexion
Have stronger nails
Have healthier hair
Be less moody
Be less depressed
Be less indecisive
Feel more motivated
Be more organized
Think more clearly and be more focused
Improve memory
Do better on tests in school
Not be dependent on over-the-counter medications like aspirin, ibuprofen, anti-histamines, sleeping aids, etc.
Stop using laxatives or stool softeners
Be free of pain
Sleep better
Have agreeable breath
Have agreeable body odor
Have stronger teeth
Get less colds and flus
Get rid of your allergies
Reduce your risk of inherited disease tendencies (e.g., cancer, heart disease, etc.)

When it comes to cravings, what is your #1 biggest challenge? Please describe in detail.

On a scale of 1-10 (10 being the highest), how important is it to you to get this challenge resolved?

Why is losing weight important to you right now?

What is going to happen if you don't lose weight soon?

Specifically how much weight would you like to lose, and by when?

Have you tried other weight-loss programs in the past? Please describe your experiences in detail.

How do you generally receive news and information about weight-loss? (Blogs, books, magazines, podcasts, etc.) Please explain in detail.

Who have been your major role models? What teachers, mentors, books, or experiences changed your life?


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