Essentially Healthy Getting to Know You Survey

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Prior to meeting for the Essential Discovery Session, I ask clients to complete a Survey that lets me know a little something about them and their goals and helps me shape our conversation. Below you will see the questions that need answered. And please note: The Survey is NOT my Client Intake Form. That comes later.

Email *

1. What is your name (please include first and last names)? *

2. What email address may I use to contact you?
*

3. I'd love to know where you are located. If you live within the U.S., in what state or territory do you live?
*

4. What city or town do you currently live in?
*

5. Are you filling this survey out for yourself or on behalf of another person?
*

6. How did you find me or who referred you?
*

7. What are your main goals for seeking nutrition counseling with Essentially Healthy? (Select all that apply)
*

Support with a specific health condition (ie: Crohns, Rheumatoid Arthritis, gas)

Lose some weight, increase energy or just a general sense of I am not feeling as good as I could

I have been chronically ill for a long time and no one has been able to help me feel better

I was referred by another practitioner (please let us know who in the space below)

Other:

Required

8. Do you have any known health or medical conditions or diagnosis that I should know about in helping you to find the best care? If yes, please explain.
*

9. What have you tried so far to address your goal? (Diets, testing, modalities, etc.)
*

Not much, just getting started

I’ve tried a few things, but I am overwhelmed by the information out there

I’ve been to more than 3 practitioners trying to figure this out, and understanding or relief is still a mystery

I have completed other Essentially Healthy programs and am interested in delving deeper into my health concerns

Other:

Required

10. Which of the following items are currently in your diet in any amount: (select all that apply)
*

Soda

Diet soda

Refined sugar

Alcohol

Fast food

Snack foods (chips, pretzels, etc.)

Dessert/candy (chocolate, cookies, candies, Twinkies, etc.)

Gluten (wheat, rye, barley)

Dairy (milk, cheese, yogurt)

Coffee

Required

11. What percentage of your meals are currently home cooked?
*

Less than 25%

25-50%

50-70%

70-100%

12. Please let us know anything else about you, your goals for nutrition counseling with Essentially Healthy or your health aspirations.
*

13. I am committed to working with individuals who are dedicated to their health and ready to receive support on their individualized journey to health and healing. I am uniquely poised to uncover and unlock the evolving templates that will deliver the results you’ve been seeking. In two or three sentences, tell me something about yourself and/or your health history that will help me get to know you before we take any further steps to dig more deeply into the details of your concerns. When you’re done, be sure to hit the submit button and expect to hear from me via email (essentiallyhealthywithkate@gmail.com) within 24 business hours.
*

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms