SASD Nutrition Coaching with Kate - Intake Questionnaire
Please complete your Intake Questionnaire prior to our first coaching call. I encourage you to be as honest and thorough as possible as the responses you provide here will serve as a benchmark for your progress moving forward.
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Name *
Age *
Email address *
Phone number *
What specifically do you want to achieve in the next 3-6 months? *
When you see yourself reaching your goal, what does that look/feel like? Describe what success means to you. Is it a number/feeling/quality of life? *
How will your life be different when you achieve these goals? Who else will be positively impacted when you achieve your goals? *
How would you like to measure progress toward your goal? If you're unsure, that's okay! We can discuss this together! *
When it comes to your relationship with food, what is your biggest challenge? *
What does a typical day of eating look like for you? (ex: number of meals per day, size of meals, do you snack?, etc) *
Do you currently track your food? If yes, describe how you track. *
Do you have an dietary restrictions (food allergies, sensitivities, etc)? *
Do you have any digestive issues? *
Do you have a diagnosed health condition? If so, please describe, along with listing any prescription medications you take. *
How would you describe your stress level? *
On a scale of 1-10, how is your energy? *
Activity level (including minutes, days per week, and type) *
Medical conditions (ex: diabetes, high blood pressure, high cholesterol) *
Do you prefer phone calls or video chat for our check ins? *
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