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Your Masterclass Intake Form
I can't wait to learn a little more about YOU so I can make the most use of your time! Please take a few short minutes to fill this out and I will follow-up w/ my recommendations and advice on how you can best prepare for this 6 week program.
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Winning Wellness Together Is the Name Of the Game!
Email Address
*
Your answer
First & Last Name
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Your answer
Age, Gender
*
Your answer
What is your address? I may mail you materials.
Your answer
How did you hear about this program?
Your answer
What is your primary goal for this Masterclass? Why is this goal important to you?
Your answer
How do you prefer to process payment? Please indicate below and pay when you are ready noting "masterclass."
Venmo @kellyoschmidt (I am in a yellow dress)
PayPal
kelly@kellyschmidtwellness.com
Zelle
kelly@kellyschmidtwellness.com
Other:
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What do you hope to accomplish in the 6 weeks? In the next year?
Your answer
What are your height and weight? What is your goal weight if your health goal includes a change?
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Your answer
Do you exercise? How often and for how long?
Your answer
What is your biggest obstacle with healthy eating and movement?
Your answer
Tell me about your sleep. How much do you get, when do you go to bed and get up?
Your answer
How many meals and snacks do you eat a day? What type of liquids do you drink?
Your answer
Do you drink alcohol? If so, how often? Do you plan to minimize or avoid it during the program? Share what your alcohol goal may be and Kelly can provide further ideas/support.
Your answer
Please take this short quiz and comment below what tendency you typically fall into. (This is a great quiz that helps me coach you, but also a great quiz to learn more about yourself and how you are motivated to meet goals).
https://quiz.gretchenrubin.com/
Your answer
Can you list everything you ate/drank yesterday?
Your answer
Please list your typical breakfast, lunch, and dinner? What do you usually snack on? (This can seem like a repetitive question, yet the more info I have the more I can zero in and guide you. Thank you in advance!)
Your answer
Do you avoid any ingredients or foods for various reasons? If yes, which? I will make note.
Your answer
Do you take any supplements? Please list what you take below with noting the brand.
Your answer
Do you take any medication? Please note below.
Your answer
Do you have any past medical diagnoses? If yes, please list the year of the dx.
Your answer
Do you have any current labs that you'd like to share with Kelly? If so, send her a separate email w/ that information
kelly@kellyschmidtwellness.com
Your answer
Please check all symptoms you currently have:
Achy joints, muscle pain, arthritis
Digestive upset: bloating, gas, nausea GI upset, IBS/IBD, and/or heart burn
Skin issues: eczema, psoriasis, acne
Hard to lose weight or stubborn weight
Mood: anxiety, stress, irritability, forgetfulness, brain fog
Low energy or energy dips throughout the day
Frequent Headaches/Migraines
Overwhelm on where to start
Cravings
Always hungry
Hard to fall asleep
Hard to stay asleep
High fasting blood sugar, over 120 mg/dL
Other:
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