Habits of Health Survey
Everybody needs a coach at some point in their lives!
What Do You Want To Do?
Develop a healthy MINDSET (Personalized one on one development)
Grow a Healthy Marriage / Partnership (Couples couching)
Learn about becoming part of our coach team.
Develop Healthy Habits in Both BODY and MIND (Includes getting to a healthy weight)
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Best number to reach you
Please enter a valid phone number.
Today's date
-
Month
-
Day
Year
Date
Age
Please describe your WHY to becoming a healthier version of yourself. (What is your main motivation? Relationships, activities, how you feel, etc)
When was the last time you remember feeling your best?
Medical Questions
Answer this section ONLY if interested in our Healthy BODY program.
Do you have any of the following?
Diabetes- Type 1
Diabetes- Type 2
High Blood Pressure
Gout
Kidney Disease
PCOS
Do you have any food allergies or dietary restrictions?
Are you taking any medications for:
Diabetes
High Blood Pressure
High Cholesterol
Thyroid
Blood Thinners
Other
Hydration
How much water do you typically drink per day?
Do you consume any other beverages?
Coffee
Soda
Tea
Alcohol
Motion
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
Do you currently exercise? If so, how many times a week?
How would you describe your daily activity level?
Eating Habits
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
Weight
Current Weight: (if you wish to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
Height:
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who is empowered to get healthy with you?
How did you hear about our programs?
On a Scale of 1-10, how motivated are you to change your current reality?
1 = Not motivated at all ~ 10 = 100% Ready!
Submit
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