Weight Loss Coaching - Welcome Survey

Weight Loss Coaching Program – Welcome Survey

I’m so excited you’re here!

Please complete the following survey to help us best prepare for your coaching sessions!

xo Cassie

Weight Loss Coaching - Welcome Survey

Name*
First Last
Age*
Birth Date*
MM slash DD slash YYYY
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
How did you hear about Cassie/our programs?*
Goals
Why did you sign up for coaching with Cassie?*
What would you love to accomplish with this program? (Physically, emotionally, mentally, family life, etc.)*
What have you tried in the past to achieve these goals?*
A Little Bit About You
Height*
Weight*
Weight you feel BEST at (goal weight)*
When was the last time you were at your goal weight?*
How much has your weight changed in the past year?*
What else is going on? (choose all that apply)*
Anything else we should know?*
What kind of diets, surgeries, or medications, if any, have you used to lose weight?*
Do you love or hate exercise?*
Which activities do you currently participate in? (choose all that apply)*
Are there any other activities that you currently participate in?*
Do you suffer from frequent muscle cramping or stiffness?*
How would you rate your current daily energy level, on a scale of 1 (rock bottom) to 10 (through the roof!)?*
On average, how many hours per night do you sleep?*
Do you have trouble falling asleep, staying asleep, or both?*
Do you wake up feeling rested, exhausted or somewhere in-between?*
Are you particularly stressed out?*
- Yes
- No
Who do you live with currently?*
Who prepares most of your meals?*
What is your occupation?*
How many hours a week do you work, usually?*
What foods are your downfall?*
Do you have any food allergies or sensitivities that you know of?*
How many meals per week do you eat at a restaurant?*
What restaurants do you eat at most often?*
Please list any meal replacement products (drinks, shakes, bars, etc.) you are currently using.*
What do you drink most days? (Coffee, tea, juice, soda, diet soda, etc.)*
Do you drink alcohol? (If so, what type and # of drinks per day/week?)*
What kinds of fat do you use for frying and sauteing at home? (Butter, margarine, coconut oil, olive oil, etc.)*
What foods do you crave?*
Please list any medications (prescription or over-the-counter) you are currently taking.*
Please list any supplements, vitamins, minerals, etc. you are currently taking.*
Is there anything else you would like us to know? (This is your opportunity to share any additional information or insight that you think would help us better serve you! 😀 )*
Finally, please upload a headshot so we have a photo for your client file!*
Max. file size: 64 MB.

Acne
Acid reflux/heartburn
Addiction
Allergies
Anemia
Antibiotic use
Anxiety
Arthritis
Autoimmune Condition(s)
Birth control use
Bloating
Cancer
Celiac disease
Chewing problems
Chronic fatigue
Cold sores
Constipation
Dentures
Depression
Diabetes
Diarrhea
Eating disorder
Fibromyalgia
Gastrointestinal disorder
Gout
Headaches
Heart disease/stroke
High blood pressure
Hot flashes
Hyperlipidemia
Hypoglycemia
Hyperthyroid
Hypothyroid
Joint pain
Kidney stones
Low libido
Lung problems
Major surgery
Mental illness
PCOS
Physical handicap
Physical injury
Pregnant/nursing
PMS or PMDD
Skin conditions
Ulcers
None of the above

Weight Loss Coaching Program – Welcome Survey

Weight Loss Coaching - Welcome Survey

Goals

A Little Bit About You