Name
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First Name
Last Name
Email
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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(###)
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What services are you interested in?
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Preferred Start Date
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MM
DD
YYYY
What is your budget?
What is your Main Health Concern?
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Describe Your Current Diet...
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Fill me in on the good and the not so great choices
Any certain foods you try to avoid or have sensitivities to?
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What foods do you crave? How often do you give into cravings?
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Are you currently taking any supplements?
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What are your favorite foods?
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Describe any diets/eating plans you've tried in the past. What worked? What didn't? Please share as much detail as possible
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How many times do you eat in a day? Include meals, snacks, treats.
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How would you describe your current diet. Give me a snapshot of what an average day looks like. Including times roughly.
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Do you experience any symptoms of bloating or discomfort after eating?
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How many servings a day do you have of each beverage?
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Water, Coffee, Tea, Fruit or Vegetable Juice, Milk, Smoothies or shakes, Pop, Alcoholic Beverages
Current Diet Dogma: Select the checkboxes that best describe your current approach to food. (Check all that apply)
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Describe your energy levels throughout the day. Do you have highs and lows? When?
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Dropdown
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1
2
3
4
5
6
7
8
9
10
Describe your main source of stres.
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How do you react to stress? Do you rely on any coping mechanisms?
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What do you do for work?
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Do you enjoy your work?
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Yes, usually
Sometimes
No
How many hours a day do you work? What's your schedule like?
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Current health conditions. Have you been diagnosed with any diseases, and/or are you on any prescribed medications?
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Have you ever been hospitalized, had any major surgery? Please describe.
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Do you have any allergies or sensitivities?
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Describe any pertinent family medical history
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Females: Are you or could you be pregnant?
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Females: Are you pre-menopausal, peri-menopausal, menopausal or experiencing menopause symptoms? Describe:
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How often do you have a bowel movement?
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Do you ever have difficult or unusual bowel movements? If so, describe:
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What do you do for exercise? Describe what types of activities, frequency, duration, intensity...
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How many hours of sleep do you get most nights?
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What time do you typically go to bed?
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What time do you typically wake up?
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Describe your sleep quality. Check all that apply.
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Please check all that apply.
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Please share any information you feel is pertinent with regard to your level of commitment through this process. What are your potential barriers? What is going to motivate you to keep going even when it gets a little uncomfortable?
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Do you have any additional notes, comments, questions or concerns that I should know about to have a successful coach client relationship?
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What is the best way to keep in touch with you?
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Text
Call
Email