1:1 Coaching Application

1

Name

First Name

Last Name

2

Phone Number

Please enter a valid phone number.

3

Email

example@example.com

4

Have you previously worked with a health coach or functional practitioner?

5

Do you have any diagnosed medical conditions (e.g., diabetes, hypertension)?

6

Current Height & Weight:

7

Are there specific health goals or concerns you want to address? (fat loss, muscle building, hormonal imbalance, gut health, etc.) Please elaborate.

8

Describe your current exercise routine (if any).

9

How many days are you working out or active with movement?

1-2 times a week

3-4 times a week

4-5 times a week

6-7 times a week

10

How would you rate the quality of your sleep on a scale of 1 to 10, with 10 being the best?

11

What stressors are you currently facing (e.g., work, family)?

12

Describe your typical daily diet. Are there specific dietary restrictions or preferences we should be aware of?

13

Are there specific hormonal imbalances or issues you would like to address through this program?

14

Are you committed to making the necessary lifestyle changes and dedicating time to this program?

15

How many hours per week can you commit to workouts, meal planning, and check-ins?

16

What are your top 3 health goals (e.g., weight loss, better blood sugar control, more energy)?

17

What challenges have you faced in past attempts to achieve these goals?

18

What are you hoping to achieve by working with me?