Health & Goal Questionnaire
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Answering the questions below will help us provide a program tailored for your specific needs.
Health & Goals Questionnaire
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Full Name *
Your answer
E-Mail *
Your answer
height *
Your answer
Age *
Your answer
Current Weight *
Your answer
Goal Weight *
Your answer
Referred By *
Your answer
Best Phone Number To Reach You *
Your answer
Describe Your Goals *
Your answer
Which Programs Are You MOST interested in? *
Do You Have Physical Limitations? If So, Please Describe *
Your answer
Do You Take Medication - If so for what? *
Your answer
Any Food Addictions? If So, describe *
Your answer
List of Beverages You Drink *
Your answer
Do You Drink Alcohol? If So, How Much & How Often *
Your answer
Describe Your Energy Level *
Your answer
Do You Regularly Drink Water, If So, When and How Much?
Your answer
Do You Eat Gluten Free, Lactose Free, Sugar Free or Any Specialty Diet? *
Your answer
Have You Ever Had Heart Trouble or a Stroke? *
Have You Ever Had High Blood Sugar? *
Do You Smoke? *
Please list medications, supplements and over the counter items you take regularly or are currently prescribed and reasons for taking them. If none, please type "none" *
Your answer
Describe in detail your biggest struggle with food "Right Now" *
Your answer
What past struggles and difficulties have you experienced with eating and/or losing weight? *
Your answer
What diet and exercise programs, protocols, plans or approaches have you tried in the past? Please List *
Your answer
By signing below, I understand and have answered the above health/medical survey questions fully and truthfully. I am aware of my responsibility to consult with my personal physician regarding my clearance to engage in a nutritional support program. I do hereby intend to be legally bound for myself and waive release of any and all rights and claims for damages I may have against the participating training facility, and/or the nutrition coach administering this program as well as the program creators themselves or anyone in connection with them for any and all injuries suffered while following nutrition advice provided to me. *
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How would you RATE my coaching call today *
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Would you recommend me to someone who is in need? *
I have read and agree to Health/Wellness/Fitness Coaching Program Terms and Conditions *
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