Please fill in the questionnaire below. By learning more about your lifestyle and habits, I can take better care of you and provide coaching that is a good fit for your goals and individual needs (it takes 5-7 minutes to complete).
First name *
Last name *
Date of birth *
Please list all of your concerns about your health, eating habits, fitness, and / or body. *
Out of the above, which are the top 3 concerns that feel most important / urgent? Why? *
What do you expect from me as your coach? *
What are you prepared to do to work towards your goals? *
How, specifically, would you like your habits, your health, your eating, and / or your body to be different? *
Have you already made changes to your habits, your health, your eating, and / or your body recently? If so, what? *
If you were to consider making further changes to your habits, your health, your eating, and / or your body, what might those be? *
Until now, what has blocked you or held you back from changing these things? *
Are you regularly active in sports and / or exercise? * NoYes
If yes, approximately how many hours per week? Fewer than 5 hours5-910-1415-1920 or more
What types of sports and / or exercise do you typically do?
Who do you live with? *
Do you have children? If yes, how many and what are their ages? *
On a scale of 1-10, 1 being insanely busy and 10 being perfectly calm and relaxed, how do you feel about your schedule, time use, and overall busy-ness? * 12345678910
On average, how many hours per night do you sleep? * 4 or fewer5678910 or more
Do you consume alcohol? If yes, how much / how often? *
On a scale of 1-10, 1 being not at all and 10 being completely, how ready are you to change your behaviors and habits? * 12345678910
Disclaimer: Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and / or fitness consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision. *
*After you submit your answers, I will get back to you via email within 24 hours!
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