Authentic Self Info Sheet
Please answer the following to the best of your ability. No worries, we will follow up with a phone call to fill in any gaps. We are already excited to get to work!
Your Name *
Your answer
How did you hear about us? *
Your answer
Phone number
Your answer
Demographics
Age
Gender
Annual income
Preferences
What are the main goals you would like to achieve in coaching?
Your answer
Do you have a individual mission/passion/purpose? If so please share
Your answer
Support system
What specialists and coaches have you worked with in the past?
What specialists/coaches are you currently working with?
Authentic self focuses on the whole person and our vision of complete wellness. What areas are especially important to you?
Please select a description that most aligns with your level of physical activity ability.
Do you follow a specific diet? If so please select the one that best applies to you.
Please select any food allergies that you have
How ready are you to make changes today in the following categories?
Changes in thinking and lifestyle design?
Changes in exercise and nutrition?
Anthropometrics
What is your weight (lb)
Your answer
Would you like your weight/body composition to be different, if so please choose the answer that fits you the best
What is your height?
Your answer
How many hours do you sleep each night?
Do you wake feeling refreshed
In the last two weeks how often did you experience the following?
0= NEVER 1=WEEKLY 2=DAILY/MODERATE 3=DAILY SEVERE
Difficulty Concentrating
Never
Daily/Severe
Fatigue
Never
Daily/Severe
Lack of appetite in the morning
Never
Daily/Severe
Fatigue that is relieved by eating/feeling energized after a meal
Never
Daily/Severe
Light headed/irritable/shaky between meals
Never
Daily/Severe
Energy dips at 3-5pm
Never
Daily/Severe
Craving caffeine at 3-5pm
Never
Daily/Severe
Difficulty STAYING ASLEEP at night
Never
Daily/Severe
Waking feeling fatigued/unrested
Never
Daily/Severe
Sugar cravings throughout the day
Never
Daily/Severe
Fatigue after meals
Never
Daily/Severe
Craving caffeine after meals
Never
Daily/Severe
Difficulty FALLING ASLEEP
Never
Daily/Severe
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