Introductory Consultation Questionnaire
Please take a moment to fill out this form to help us get to know you.
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Name: *
Age: *
Height (cm): *
Occupation: *
What are your goals? (Select as many as relevant to you.) *
Required
I am enquiring about: *
On a scale of 1-10 how motivated are you to achieve your goals? *
I'd rather watch Netflix.
I'll do what ever it takes!!
Do you have, or have you had any health conditions? *
Required
If you answered yes to any of the above, please provide details. In addition, please describe any other health conditions you think are important.
Do you have, or have you had any pain or major injuries?
Do you have an ideal time frame to achieve your goals? *
What has kept you from starting sooner? *
How many days per week are you currently exercising? *
What type of exercise are you doing or done in the recent past? *
Required
Have you tried to change your body composition in the past? *
If you answered yes, what have you tried?
Do you currently take any supplements? *
If you answered yes, please provide details.
Do you currently take any prescribed medications? *
If you answered yes, please provide details.
Have you ever used a nutrition program? *
If you answered yes, please provide details.
On a scale of 1-10, how would you rate your overall stress levels throughout the course of the day? *
Very Low
Very High
If you answered 7-10, please provide details. I.e. When do you experience high levels of stress? At what time of the day? What causes you to feel stressed etc?
How many hours of sleep do you average per night? *
If you're sleeping is poor. Please describe your usual sleeping patterns. For example, is your sleep interrupted? Do you find it hard to fall asleep? Do you find it hard to wake up etc?
On a scale of 1-10, how would you rate your overall energy levels throughout the course of the day? *
Very Poor
Very Good
If your energy is generally poor. Please describe when you have the highest energy and when you have the lowest.
On a scale of 1-10, how would you rate you digestion? *
Very Poor
Very Good
If you answered 1-4, please provide details.
On a scale of 1-10, how would you rate your appetite? *
Always Feel Hungry
Never Feel Hungry
If you'd like help with your appetite, please provide details of how you feel generally each day in regards to level of satiety.
Do you currently have self care practises in place regularly? For example. Journalling, Mindfulness, Breath work, Hot Baths. *
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Thank you and we can't wait to meet you soon.
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