Functional Health Coaching
*Please ensure you are aware of coaching costs before applying* If you are not sure what plan is best suited for you - please send Kristin a DM on instagram.
What coaching package are you enquiring for?
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PREMIUM PACKAGE:
BASIC PACKAGE:
SELF-GUIDED HEALTH PROTOCOL
COMP PREP
Name
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First Name
Last Name
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
What do you do for work? Is it physical or sedentary?
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Gender
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Male
Female
Date of Birth
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Month
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Day
Year
Date
Age
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Height (in CM)
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Weight (in KG)
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Instagram handle
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What are your 3 main health goals?
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e.g. reduce stress, prioritise my health, reduce weight, build muscle, improve gut health, more structure with my diet, have a better relationship with food, improve self-confidence, work on my self-talk, have a more positive mindset...)
What is your current diet like? - Please be specific - what foods are you currently eating, how many meals per day etc
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Do you have any food intolerances/allergies?
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Do you have any medical conditions? Please be specific - e.g. Diabetes, Crohns, PCOS, Autoimmune etc
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If you are on any medications, please list them.
Please list the foods that you dislike
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What is your sleep like? How many hours per night?
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Do you have children? If so, how many?
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How are your stress levels?
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What supplements/vitamins do you currently take?
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Are you on any drug enhancements/ or have you taken any before?
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What do you do for exercise? (Please include how many days per week)
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This can include: Weight training, walking, yoga, etc
What time of the day do you train?
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Do you have any injuries or limitations?
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Gut health: Do you suffer from any of the following?
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Reflux/heartburn
Bloating/abdominal discomfort
Constipation
Diarrhea
IBS
SIBO
Celiac Disease
Nausea
None of these
Other
Lifestyle + Mental: Do you regularly experience any of the following?
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Stress/Anxiety
Low self-confidence
Negative self-talk
Limiting thoughts/beliefs
Self-sabotaging
Depression
Poor relationship with food
None of these
Other
Do you wake up frequently through the night to pee?
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Do you experience hot flushes or night sweats?
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Do you feel dizzy when exercising?
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Do you experience energy crashes throughout the days? If so, what time of the day roughly?
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FEMALE ONLY: Do you get a regular cycle?
Does it arrive on time? Do you experience heavy or bleeding.. etc
FEMALE ONLY - When is your cycle due?
FEMALE ONLY: Are you on birth control?
FEMALE ONLY: Do you experience sore breasts or aches around your cycle?
FEMALE ONLY: Do you experience stomach pains during ovulation (the lead up) and during your period?
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Do you experience pain on one side of the stomach? If so, which side?
Anything else you would like me to know about your health/lifestyle?
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