Whole30 Coaching Intake From
Please answer the following questions as **truthfully** as possible, so that I may better serve you as a coach during your Whole30 journey.
My Name (first + last name)
Where are you located? (City + State)
Early Bird January Whole30 (On or Before December 15, 2019)
Returning Client (January Whole30)
Word of Mouth
Have you completed a Whole30 or started one previously?
How many rounds have you done?
Which, if any, Whole30 books do you have or have read?
It Starts With Food
Whole30 Fast and Easy
Whole30 Day by Day
Whole30 Slow Cooker
Whole30 Friends and Family
What do you expect to get out of your Whole30?
What are your top 1-2 concerns or reservations about the Whole30, Reintroduction, Food Freedom?
How much total time do you realistically have each week to cook & meal prep? (does not need to be on only one day, could be hours on multiple days)
2 Hours or Less
Do you enjoy cooking?
Do you like to try new recipes or prefer to keep it simple?
Keep It Simple Silly
Always up for something new
What types of recipes are you most likely to use? (mark all that apply)
One Pan or Sheet Pan Meals
Crock Pot/Instant Pot
Where do you grocery shop the most?
What is a resource or two that you think will help you successfully complete a Whole30 and manage your Food Freedom? (Daily e-mails or communication, recipes, shopping lists, etc)
What kind of tools work for you regarding mindset changes? (Check all that apply)
Affirmations (verbal, written, etc)
Self-Inquiry practice (meditation or other spiritual practice)
Being around/listening to others that are inspiring/match your desired mindset
Reading Articles + Books
Listening to podcasts
Share any personality quiz results like Four Tendencies, Enneagram, Myers-Briggs, etc
Are you currently under a doctor's care?
Any recent significant weight changes over the past year? 10% or more? Ex: gastric bypass, lengthy illness, medication
Daily Water Intake
0 - 50 oz
50 - 100 oz
Medical History please describe in detail. (Hypertension, diabetes, heart conditions, eating disorders, IBS, alcohol/drug abuse, etc.) Anything that will color our coaching conversations. Feel free to go in depth here, and please answer TRUTHFULLY.
Abnormal recent lab values (blood sugar, triglycerides, cholesterol, etc)
Surgeries? How long ago and procedure
Are you currently on any medication? State for what condition.
Caffeine Consumption (type and frequency) Ex: black coffee every morning, 2 diet cokes daily, etc.
Sugar Consumption and Type (Artificial sweeteners count here, too) Example: 1 splenda in coffee, clif bar as a snack, dark chocolate at night, etc.
Food Allergies or Intolerances?
Exercise Regimen and Schedule - Ex. 1 hour cardio 6 days a week, 3 days of walking, etc.
8 or more
Less than 6 hours
Can get to sleep, but not stay asleep
Hard to get to sleep
Tired upon waking
Biggest Barrier to healthy living?
Lack of family support
Set in ways
Lack of Understanding
Have you ever been in treatment for disordered eating?
Any injuries that prevent exercise?
Informed Consent --Whole30 services are intended to promote general health and wellness. This program will focus on motivation and accountability. Nicole Cooke will not be providing customized or clinical nutrition advice. We will simply provide general healthy living and nutrition tips as outlined per the Whole30 guidelines. Whole30 is not intended to replace physician care or medical intervention. All assessments, suggestions and/or consultations are about lifestyle and habits and are based on your input, and are not intended to diagnose, treat or cure any disease or ailment. Nicole Cooke will help you through the program with our many years of Whole30 practice and experience. You acknowledge you have checked with your Doctor and your physician has recommended you follow the Whole30 plan. In the State of Florida, only a Registered Dietitian can provide nutritional advice. Therefore, if anything comes up that is not covered by Whole30 website or books or additional resources, you will be referred to one of our Registered Dietitian colleagues and asked to make an appointment with your doctor. You acknowledge and agree to accept all responsibility for reviewing diet and nutrition suggestions with a licensed medical professional before following the Whole30 program. As with any program, there may exist inherent risks which may be relative to your state of health, fitness, awareness, care, and skill to which you conduct yourself. You agree that it is your responsibility to inquire about any recommendations with which you are not familiar, and provide any information which may limit your participation in the Whole30 program. Results and changes in your general health and wellness may vary depending on medical conditions, medications, and accuracy in following suggested guidelines. As your general health and wellness may change with modifications in diet, nutrition, and lifestyle, physician-prescribed medications may require modification. It is your responsibility to discuss this with your physician. Never reduce or eliminate physician prescribed medications without the direction of your physician or medical care provider.Your personal and health information will remain confidential and will not be shared without your consent. Nicole Cooke reserves the right to refuse services to any individual or refer at any time to appropriate medical professionals. Acknowledgement & Consent to Receive Services. I have read and understand the above disclosure about the Whole30 Motivation and Accountability services offered by Nicole Cooke. I have discussed with Nicole Cooke the nature of the services to be provided. I understand that Nicole Cooke is not a licensed physician and that Whole30 coaching services are not licensed by the state, medically authorized, nor sponsored by any licensing bodies. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor or licensed health provider. I have consented to use the services offered by Nicole Cooke and agree to be personally responsible for the fees in connection with the services provided to me. By signing below, you agree to the above terms and conditions for participation in Whole30 motivation and accountability with Nicole Cooke. I agree with the above statement. *
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