Questionaire

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Questionaire

This questionare is required to be considered for coaching. All information is completely confidential.

First name:
Last name:
Evening phone number:
Daytime phone number:
Email Address:
City you currently live in:
Do you eat breakfast?:
Do you feel tired and worn down by lunch time?:
How many glasses of water do you typically drink per day?:
How many children do you have currently living at home?:
Are you currently pregnant?:
How many days/week do you drink alcohol?:
Do you smoke cigarettes?:
Are you currently taking prescription medications?:
How many hours of sleep do you get daily?:
Are you addicted to sugar?:
Are you addicted to caffeine?:
Would you say your current health and eating habits are great, fair, or poor?:
What is your main reason for wanting to make a change and learn new habits?:
On a scale of 1-10 How committed are you to changing your current eating/health habits?:
Additional Comments: