Intake Questionnaire-Karen K Coaching
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Email address
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First and Last Name
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Age
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Height
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What is your current weight and how has that changed over your adult years?
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If weight improvement is one of your coaching goals, what is your goal weight?
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Where do you live in now (city, state, country)? Is it rural, suburban or city-like?
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What is your living situation like? Do you have a spouse/significant other? What is his/her name? Do you have children? What are their ages/names? Are they supportive/interested in eating healthy?
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Do you exercise? If so, what type and for how long/how often?
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What would you say your biggest struggle is with healthy eating?
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If weight-loss or weight-gain is relevant to your goals, have you tried any diets in the past and have they worked? Please offer details -- I'd like to get an idea of your history with dieting.
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Do you have any experience with plant-based eating? If yes, please explain.
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What is the greatest outcome you would love to achieve from doing a Private Coaching Program with Karen? (i.e. weight-loss, ending binge-eating, long-term health, disease prevention/reversal, improve relationship, etc)
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If you could change 3 things in your life & relationships over the next 3 months, what would they be, in order of importance?
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What do you think are your biggest obstacles in reaching your ideal potential/health/weight?
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Is there anything else you'd like me to know about your situation?
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