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3 Session Heart Health Form
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Email
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Your email
First name
Your answer
Last name
Your answer
Why are you seeking coaching? What issues or roadblocks are you currently facing?
Your answer
Age
Choose
30s
40s
50s
60s
70s
80s
90s
Occupation
Your answer
Heart Health
I have had a heart attack
I have not had a heart attack but have a family history
I have not had a heart attack and don't have any family history
Other:
Clear selection
Please provide more detail about your heart health:
Your answer
Do you currently have a good medical follow-up with a cardiologist?
Choose
Yes
No
Please describe your diet.
Your answer
Do you drink alcohol?
Never
1-2 drinks/week or less
2 drinks/day
> 10 drinks/week
Do you smoke?
Yes
No
What is your stress level at the moment?
Low
High in certain circumstances ex: work
High - I often feel tense
Clear selection
How often do you exercise?
No strenuous exercise
Cardio 2-3x/week
4-5x/week
Other:
Clear selection
What is your current satisfaction with your life at the moment:
Low
1
2
3
4
5
6
7
8
9
10
High
Clear selection
How do you believe working with a coach will improve your situation?
Your answer
What would a win look after we have worked together?
Your answer
What is you usual time zone/location?
Your answer
Please provide any additional detail that you'd like me to know.
Your answer
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