Getting to Know You Survey Questions
Pre-Strategy Questionnaire
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
How did you find me or who referred you?
What are your main goals for seeking Health Coaching with Flourish with Lisa?
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
(please specify more specific thoughts/goals for seeking health coaching)
Do you have any known health or medical conditions or diagnosis that we should know about in helping you to find the best care?
Yes
No
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
Other
if you responded "Other", please specify
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
What percentage of your meals are currently home cooked?
Less than 25%
25-50%
50-70%
70-100%
Submit
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