Whole30 Coaching Intake Form

Hello!

I am excited about the opportunity to work with you!

Now, let's get to know each other. This form has a lot of questions so make sure you have 20 minutes (ish) to complete it. I've tried to leave you plenty of room, so let the answers flow! The more I know about your own personal journey, the better I can support you.

Name *

First Name Last Name

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

Date of Birth *

Date

Your Height and Weight (approximately) *

The Whole Pickle Whole30 and Food Freedom coaching services are intended to promote general health and wellness and are not intended to replace physician care or medical intervention. All nutritional assessments, suggestions, and/or consultants on health, nutrition, diet, and lifestyle are based on your input and are not intended to diagnose, treat, or cure any disease or ailment. You acknowledge your responsibility for reviewing any diet, lifestyle, or nutrition suggestions with your primary care physician or another licensed medical professional before following said suggestions. As with any program, there may be inherent risks that may be relative to your state of health, fitness, awareness, care, and skill to which you conduct yourself. You agree that it is your responsibility to inquire about any recommendations with which you are unfamiliar and to provide The Whole Pickle with any information which may limit your participation in the Whole30 program.

Results and changes in your general health and wellness may vary depending on medical conditions, medications, your adherence to the guidelines, and bio-individuality. As your general health and wellness may change with any modifications to your diet, nutrition, and lifestyle, physician-prescribed medications may require modification. It is your responsibility to discuss this with your physician. Never reduce or eliminate physician-prescribed medications without discussing it with your physician or health care provider.

Your personal and health information will remain confidential and will not be shared without your consent. Cyndy and The Whole Pickle reserve the right to refuse services to any individual.

By clicking that you agree below, you acknowledge that you have read that above disclosure about the coaching services offered by Cyndy at The Whole Pickle. I understand that Cyndy is not a licensed physician and that these coaching services are not licensed by the state, medically authorized, or sponsored by any licensing bodies. I acknowledge that it is my responsibility to maintain a relationship with my primary care physician or another licensed medical provider. I consent to use the services provided by Cyndy at The Whole Pickle and agree to be personally responsible for the fees in connection with the services provided to me. I agree to the above terms and conditions for participation in Whole30 or Food Freedom coaching with Cyndy at The Whole Pickle.

I agree with the above statement. *

Yes

Enrollment in the "Who Quits Healthy" community is MANDATORY. Participation is key to your Whole30/Food Freedom Success. (Note: your fee for WQH is a part of your overall coaching fee.) *

Understood.

Tell me about your "why" for completing this Whole30. *

Have you completed a Whole30 before? *

Yes, including reintroduction Yes, I completed the 30 days, but did not complete reintroduction Yes, but I did not complete the 30 days or reintroduction No

If you didn't finish or did not do reintroduction, what was your reason for stopping?

Have you ever been coached by a Whole30 Certified Coach? *

Yes No

Which, if any, of the Whole30 Books/Materials have you read? *

The Whole30 It Starts With Food Whole30 Cookbook Food Freedom Forever Whole30 Day By Day Whole30 Fast N Easy Used online resources from Whole30.com

Tell me how you feel about cooking. Example: "I cook several times a week and love it" OR "I am a cookbook/recipe lover." OR "What do you mean cook?" OR "I cook because I have to, but I don't enjoy it." OR "I'm the next Food Network Star." *

How many times do you eat out weekly? *

Less than 5 times 6 - 10 times More than 10 times

Tell me more about your restaurant habits? Example: "I go out to lunch daily with my coworkers." OR "I go out to eat with my family every Friday night." *

Any recent significant weight changes within the last year? (Lengthy illness, medication, gastric bypass, etc.) *

Tell me about your medical history. Please describe in detail. Feel free to go in-depth here (Hypertension, diabetes, heart conditions, eating disorders, IBS, alcohol/drug misuse, etc. - we'll talk surgeries in the next question.) *

Any surgeries? Please list the procedure and approximate date. *

If you've had any recent labs with abnormal results, tell me more. *

Please list any medications and supplements that you currently take. *

Any food allergies or intolerances? *

Gluten/grains Dairy Soy Nuts Legumes Nightshades Eggs Other None that I am aware of

If you do have any food allergies or intolerances, tell me more here. *

Do you have ever been treated for disordered eating? *

Yes No

What is your typical daily water intake? *

Less than 25 ounces 25 to 50 ounces 50 - 75 ounces 75 - 100 ounces Over 100 ounces

What's your average sleep per night? *

4-6 hours 7-9 hours 10 or more hours

Tell me more about your sleep. (Example: "I have trouble falling asleep." OR I wake up in in the middle of the night and have a hard time getting back to sleep.") *

Do you smoke? *

Yes, Daily Yes, Occassionally No, never No, I quit

If you quit smoking, when did you quit?

Do you consume alcohol? *

Yes, regularly Yes, occasionally No, it's never been my thing No, I am in recovery AKA "not drinking right now" AKA a sober alcohol/addict

If you are in recovery, please share with me how long you have been in recovery and anything else you want me to know.

Talk to me about your caffeine consumption (type and frequency). Example: "I drink 2 shots of espresso every morning and 1 diet coke per week." *

Talk to me about your sugar consumption and type. Please include all types of sugar and sweeteners - both real and artificial. Example: "1 Splenda in my coffee, a teaspoon of honey in my afternoon tea, a Larabar with the tea, and a piece of dark chocolate every night" *

Tell me about the role of movement/exercise in your life. Examples: "I get 10k steps a day and it's just a part of how I live." OR "I go to the gym 4 times a week but I hate it." *

Any injuries or health conditions that affect your movement or ability to exercise? *

Biggest barrier to healthy living? *

Lack of Support Finances Stress Time Lack of understanding Too set in my ways Other

Tell me more about your answer above. *

Is there anything else you would like me to know as you begin your Whole30/Food Freedom journey? *

How did you find Cyndy at The Whole Pickle? *

Social Media Whole30 Coaches Page Word of Mouth Other