Name
Email
Telephone number
Age
What is your current weight?
What is your height?
What are your wellness goals?
If weight loss is your primary goal, what would you like to lose?
How do you imagine your life will improve when you reach your goal(s)?
What have you tried in the past for fitness/ and or weight loss?
Why do you think other programmes failed you? What was missing?
How often do you exercise for at least 20 minutes?
If you're not currently exercising when was the last time you did?
Which of these statements ring most true for you? You can count on me!
Convince me why and I'll comply.
You can't make me.
Discipline is my freedom.
What were your biggest obstacles when you tried to lose weight in the past?
This time, what do you feel are your biggest challenges that could get in the way?
On a scale from 0-10 (10 = I am completely overwhelmed), how overwhelmed do you usually feel?
On a scale from 0-10 (10 = I completely struggle), do you struggle being a perfectionist?
When things get challenging, what reasons do you come up with to convince yourself its time to quit?
Is there a type of coaching style or type of feedback that would demotivate you? Why?
What's the best way to offer you feedback or suggest a way for you to change?
Which do you prefer: A more structured plan.
A more flexible approach.
On a scale from 0 to 10 (10 = I feel totally supported), how supportive is your employer when it comes to your wellness?
Are you in a relationship? If so, is your partner supportive of your decision to commit to your health? I'm not in a relationship.
I'm in a relationship, and they are supportive.
I'm in a relationship, but they are not supportive.
Do you have children?
Do you have a history of depression or anxiety?
Have you struggled with disordered eating in the past?
Do you have any dietary restrictions or requirements that you'd like us to know about?
If you could have one superpower, what would it be?
Is there anything that you want us to know that you haven't had chance to share?
Will you be committed to reach out to me if you're tempted to quit the programme?
Complete a 3-day Food Diary. It doesn’t need to be detailed but an honest log of what you ate for breakfast, lunch, dinner, and snacks with times (e.g. Day 1: porridge with banana @ 8.30am etc).
Submit
