Application Form for Revive & Thrive Metabolic Health Coaching Program
Thank you for your interest in the Revive & Thrive Metabolic Health Coaching Program! We are excited to learn more about you and how we can support your journey towards improved metabolic health and well-being.Please complete the following form to help us understand your current health, lifestyle, and goals. Your responses will assist us in tailoring the program to better meet your needs and ensure you get the most out of our coaching sessions.This form should take approximately 10-15 minutes to complete. If you have any questions or need assistance, please feel free to contact us.
Personal Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
What is your age?
How did you hear about Revive and Thrive?
Email list
Facebook
Instagram
Other
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Medical History
Do you have any current or past health conditions? (Please list)
Are you currently taking any medications? (Please list)
Do you have any food allergies or intolerances? (Please list)
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Dietary Preferences
How many times do you typically eat in a day?
1-2
3-4
5 or more
Are there any foods you avoid or dislike? (Please list)
Do you follow a specific eating style? (e.g. vegetarian, vegan, gluten-free)
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Lifestyle and Habits
Do you smoke?
Yes
No
How often do you drink alcohol?
Rarely or never
Once a week
Several times a week
Daily
How often do you engage in at least 30 minutes of moderate intensity cardiovascular training (e.g. walking, cycling, dancing) in a week?
Rarely or never
1-2 times
3-4 times
5 or more times
How often do you engage in strength training (e.g. weights, pilates, bodyweight exercises) in a week?
Rarely or never
Once
2 or more times
How many hours of sleep do you typically get?
Less than 5
5-6
7-9
More than 9
How would you rate your current stress levels?
Low
Moderate
High
Very high
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Your Goals and Program Fit
What are the main goals you'd like to achieve across the course of the program?
If weight loss is a goal for you, how much weight are you aiming to lose within the 8 weeks?
To date, what are the main challenges you have faced in achieving these goals?
What are your expectations from the Revive and Thrive Metabolic Health Coaching Program?
Why do you feel you would be a good fit for this program?
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Availability
Please tick the times you are available for group coaching calls (all times are Australian Eastern Standard Time - AEST)"
Tuesday at 6 pm (22 October, 5 November, 19 November and 3 December)
Wednesday at 11 am (23 October, 6 November, 20 November, 4 December)
Friday at 7:30 am (25 October, 8 November, 22 November, 6 December)
Friday at 2:30 pm (25 October, 8 November, 22 November, 6 December)
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Additional Information
Is there anything else you would like us to know or any specific questions you have about the program?
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