Coaches Pat & Karen - Let's Get Started Questionnaire & Metabolic Quiz

Questionnaire & Metabolic Dysfunction Quiz - Coaches Pat & Karen Schatzline

It is a joy to help people transform their lives in every way!
Some Questions to Help Us Get Started:

Please complete this form to schedule a free assessment
Name*

First NameLast Name
Contact Number*
Email
example@example.com
calltextemail
Best day/time to contact you?*

DayTime
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
FacebookFamily or Friend referred meInstagramOther
YesNo
AWAKEN -

Let's Talk About Your Goals:
I'd like to lose overall weightI need to lose body fat to show off my musclesOverall healthOther
What is your why/your main motivation for wanting to make changes? (Is there an event you are working towards? Fit into your clothes better? Want to clean up your lifestyle?) Be specific!
Describe where you would like to be in your health? What is your ideal weight or what is your health goal?
Allergies/Current Conditions

Just a few simple questions to help us know you better.
Conditions/Allergies *
Do you have any conditions or allergies?
If yes, please specify:*
YesNo
PregnantBreastfeedingNo
If yes to breastfeeding - how old is your infant?
Sleep, Hydration & Motion

it is all important for overall health!
How many hours of sleep a night do you get
How much water do you drink a day?
How much soda/coffee a day?
How much alcohol?
1-3 - low4-6 - mild6-8 - high8-10 - great
What physical activities do you like to participate in?
How many times a week do you exercise?
Stress and Eating Habits & Weight:

Finding out a bit more about you to best help you!
1-3 - mild4-6 - moderate6-8 - high8-10 - very high
How many meals a day do you eat?
yesnosometimes
Current Weight
Goal Weight:
If you have tried to lose weight before, what did you find was the most frustrating or what did you find that worked well? Did you maintain after your loss?
Bariatric surgeryGLP1 shotsWeight loss pillsOther
highly sensitivemoderately sensitivelow sensitivity
The program I coach is a habit transformation system that addresses lifestyle changes in the form of nutritional and behavioral support. However, we have combination therapy options available to those who desire both medically supported weight loss (MSWL) in conjunction with lifestyle transformation. Do you desire to discuss a combination approach (MSWL/Optavia)? Do you think it would be a good fit for you?
Metabolic Dysfunction Quiz:
Lose stubborn fat and tone upFix bloating and feel lighterBalance my hormones / stop mood swingsGet my energy and motivation back
I lose pounds, then it all comes backI feel exhausted and crave everything in sightNothing changes - my body just doesn't respondMy digestion and mood actually get worse
high stress / poor sleep most nightsI wake up at 3am wired and tiredI sleep okay but feel unrestedI manage stress well and sleep solidly
Bloated or gassy most daysConstipated or irregularSensitive stomach - even "healthy" foods bother mePretty regular - no major issues
4-5 days a week2-3 days a weekRarely - mostly cardio or classesAlmost never exercise right now
Crash hard mid-afternoonFeel tired no matter whatWired at night, hard to wind downSteady and Consistent
1-3 months6 months or more1-2 yearsFeels like forever
I skip meals without meaning toI snack all day but never feel satisfiedI eat 1-2 bigger meals but still feel hungryI eat consistently and feel balanced
Sugar hits me hard at nightCarbs and salty snacks are my weaknessI crave everything when I'm stressedI don't really struggle with cravings
It feels slow no matter what I tryIt is up & down - some good, some notIt tanked after kids, stress, or ageIt feels steady and strong
Last Question ... Is there anyone in your life you would like to get healthy with you?
Thank you so much. Looking forward to speaking with you!! CLICK THE LINK BELOW TO SUBMIT & WE WILL BE IN TOUCH SOON!
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Questionnaire & Metabolic Dysfunction Quiz - Coaches Pat & Karen Schatzline

Some Questions to Help Us Get Started:

AWAKEN -

Allergies/Current Conditions

Sleep, Hydration & Motion

Stress and Eating Habits & Weight:

Metabolic Dysfunction Quiz: