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Health History Questionnaire
I'm looking forward to getting to know you better and working with you. Please fill out all the questions as completely as possible prior to our initial session. ~Karla
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Full Name *
Email Address *
Location/Timezone (Example: Texas, CST/MST or New York, USA/EST) *
Phone Number *
Occupation *
Family/Living Situation? (Live alone? Partner? Married? Have kids? How many? Pets? Names of pets.)
Height *
Weight *
List your main concerns or goals which have prompted you to seek out health coaching. *
Do you experience any of the following? *
Required
If you checked the box for any of the starred items above, please elaborate. (Write N/A if not applicable). Or, if you struggle with something else you can share the details here. *
If you are desiring weight loss, what is your desired weight?
Please describe your relationship with food and your body as it is right now. What exactly are you struggling with? *
What is your biggest obstacle(s) in reaching those goals? What is getting in your way? *
How is this issue affecting you in your life? Be specific. How does it affect your relationships, confidence, career, etc? *
What do you need the most help with? Check all that apply. *
Required
What have you done in the past to lose weight, or address the above issues? *
Briefly describe your current daily eating habits. Do you follow a certain style of eating (dairy-free, gluten0free, paleo, vegan, etc.). Do you avoid certain foods? Which foods do you eat a lot of? *
If you take any supplements or medications on the regular, please list them here.
Check all of the factors that apply to your current lifestyle and eating habits. *
Required
How did you find out about my program? *
Required
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