Insiders Coaching Pre-Session Intake Questionnaire

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Coach

First

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Coach Email

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Member Email

By filling out this questionnaire, you agree to Robyn Openshaw and any health coach working with you privately to access this information. Other certified coaches we employ may see your information while searching our records for their own clients, but your information will be shared with no third parties. GreenSmoothieGirl and health coaches do not provide medical care or diagnosis or prescriptions.

You can save and continue later if needed. Just scroll to the bottom and save your progress.

First Name(Required)

Last Name(Required)

Email address you used to book your health coaching session(Required)

Enter Email Confirm Email

Location(Required)

City State

What is your main reason for scheduling a session with a health coach?(Required)

How many time do you exercise each week?(Required)

What types of exercise do you practice?(Required)

Cardio: walking, running, biking, swimming

Strength: weights, resistance, crossfit

Balance & Flexibility: yoga, stretching

Core: pilates, circuit

Athletics: team sports, competition

Extreme: marathon, ironman

Other

How often do you eat processed foods?(Required)

Amount of your diet comprised of processed foods.(Required)

How often do you eat meat and dairy?(Required)

Amount of your diet comprised of meat and dairy.(Required)

Amount of your diet comprised of whole foods,(Required)

Cups of coffee per day.(Required)

How often do you consume alcohol?(Required)

Servings of alcohol per occurance.(Required)

Please describe your daily average diet.(Required)

Please list your top 5 health goals in order of importance.(Required)

Would you like to release weight?(Required)

Yes

How many pounds?(Required)

Please enter a number greater than or equal to 1.

What medical diagnoses are you struggling with?(Required)

What pharmaceutical medications are you taking, or have taken in the last 5 years?(Required)

What supplements are you taking?(Required)

Who is involved with your medical treatment (standard-of-care doctors or functional-medicine practitioners)?(Required)

Please describe any surgeries you have had and details about resulting health issues after those surgeries.

Please list any toxic exposures you have experienced that may be related to your health (living in a house with mold, shop teacher, dentist or dental hygienist, grew up on a farm, fought in Desert Storm, etc).

Any details about alcohol consumption you wish to share?

Would you like a copy of your answers emailed to you?(Required)

Yes

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Email Address to receive answers

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Date

Comments

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INSIDERS COACHING PRE-SESSION QUESTIONNAIRE

THANK YOU!