Diabetes Dominator Strategy Session Questionnaire
***IMMEDIATELY AFTER COMPLETING THIS QUESTIONNAIRE, YOU WILL SEE THE LINK TO CLICK AND SCHEDULE YOUR FREE COACHING CONSULTATION***

Congratulations! Taking the time to fill this questionnaire out shows that you're somebody who is dedicated to taking action to create your own SUSTAINABLE healthy lifestyle. Your answers will help make your strategy session with Daniele tailored to your specific needs and goals.

#1 *
IN THE BOX BELOW, PLEASE ENTER YOUR NAME, EMAIL, AND PHONE NUMBER. WITHOUT THIS INFORMATION WE MAY NOT BE ABLE TO CONTACT YOU.
Your answer
#2 *
What type of diabetes do you have? At what age were you diagnosed? How old are you now? If you are filling this form out for someone else, please answer the questions and state your relationship to that person.
Your answer
#3 *
How many times a day do you check your blood sugar with a glucometer? Do you wear a CGM and/or an insulin pump?
Your answer
#4 *
What was your last Hemoglobin A1c value and when was it taken?
Your answer
#5 *
What do you generally have for breakfast, lunch, dinner, snacks? How many ounces of water do you drink per day? Do you have any issues or habits around food that you struggle with?
Your answer
#6 *
What do you do for exercise? Are you where you would like to be with your physical fitness? What specifically are your challenges?
Your answer
#7 *
Describe your overall outlook regarding diabetes, and your overall outlook regarding your own life. In what ways would you like to improve your emotional health/mindset?
Your answer
#8 *
How many hours of sleep do you get per night? Are there any improvements you would like to make here?
Your answer
#9 *
What are your main challenges and what is your top goal you are aiming to reach in the next 3 months?
Your answer
#10 *
How committed are you to do whatever it takes to make lasting, SUSTAINABLE, positive changes in your health habits and choices, and in your life? Rate your commitment using a scale from 1 - 5, where 1 = I'm completely satisfied with staying where I am currently, and 5 = I'm Beyond Ready!
Your answer
#11 *
How did you hear about this opportunity for a free coaching consultation?
Your answer
#12 *
Please initial here to confirm that you understand that 1) you will be prompted to schedule a time for your free coaching consult once you submit this form and 2) if you need to reschedule your free coaching consult after you initially schedule it, you must contact us at Coach@diabetesdominator.com to let us know BEFORE your originally scheduled session. If you do not show up for your session, you will not be able to schedule again.
Your answer
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