Intake Questionnaire-Karen K Coaching
Email address *
First and Last Name *
Age
Height
What is your current weight and how has that changed over your adult years?
If weight improvement is one of your coaching goals, what is your goal weight?
Where do you live in now (city, state, country)? Is it rural, suburban or city-like?
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?
Do you exercise? If so, what type and for how long/how often?
What would you say your biggest struggle is with healthy eating?
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.
Do you have any experience with plant-based eating? If yes, please explain.
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)
If you could change 3 things in your life & relationships over the next 3 months, what would they be, in order of importance?
What do you think are your biggest obstacles in reaching your ideal potential/health/weight?
Is there anything else you'd like me to know about your situation?
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