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Podcast Guest: Health Coaching Session
In this coaching session, we will go over one area you are struggling with and figure out your next step.
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Email
*
Your email
Name
*
Your answer
Today's Date
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MM
/
DD
/
YYYY
Phone Number
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Your answer
Do you currently live in the U.S.A.?
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Yes
No
How would like your name used on the podcast episode?
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First & Last Name
First name only (great option if you want more privacy)
Anonymous
Do you have a business or anything you would like shouted out on the show? (If you have a website or social media link you would like to share, please add below)
Your answer
Do you have a specific topic you would like to be coached on? If you are not sure that is okay.
*
Your answer
What is the last thing you googled about health?
Your answer
Current Level of Exercise
No exercise
2-3 times a week
4-7 times a week
Other:
Clear selection
What is your average level of movement each day?
Sedentary (desk job)
Some movement (periods of walking, cleaning, etc every 2-3 hours)
Moderate movement (Constantly on the move)
Lots of movement (very physical job)
Clear selection
Do you struggle with sugar cravings?
Yes
No
Sometimes
Clear selection
Do you struggle with emotional or stress eating?
Yes
No
Sometimes
Clear selection
What are your major struggles in your health and wellness?
Your answer
What have you tried that hasn’t worked?
Your answer
What have you tried in the past that has helped you?
Your answer
Do you have or want to work towards any goals for your fitness or nutrition?
Your answer
How would you describe your sleep? Check all that apply
I typically get 7-9 hours a night
I fall asleep easily and stay asleep
I struggle to fall asleep
I struggle to stay asleep
I don't get enough sleep
On scale of 1-10 rate your current stress level this week.
Very low. I have no stress.
1
2
3
4
5
6
7
8
9
10
Very high as in I’m experiencing physical manifestations of stress frequently like disabling anxiety or depression.
Clear selection
Please add any other information you think that would be helpful. For example, health conditions, injuries, stressors, pregnancy….
Your answer
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