Personal Health Survey

Personal DEEP DIVE Survey

Please fill out the following survey and press Submit.
Your responses will be sent directly to Karrie Gregson and treated confidentially.

If you prefer, you may print out the survey and deliver in person.

Print a hard copy

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Name *

First

Last

Street Address *

City *

Postal Code *

Phone Number (Cell or Home) *

Phone Number (Work) *

Email *

What do you really want? Here are a few questions that are very important to start so I can know you better and help you more.
I then ask for more specifics on your eating and lifestyle.

What is your ultimate goal? Be specific and descriptive. If you could do or have absolutely anything, what would that be? What would make you shine? What really lights you up? *

Why? What makes you uncomfortable about this the way it is now? How do you really feel about this? How long have you felt this way? *

Do you have something coming up to work towards? Long term or short term? *

30 Day Goal *

90 Day Goal *

1 Year Goal *

On a scale of 1-10, how important is it for you to reach these goals? *

How would you feel if A) You were right now in your desired situation (goal)..if you were living it now. What does it feel like? *

How would you feel if B) Things never changed and you stayed right where you are and in 1 year..you are in the exact same situation? *

In addition to your desired outcome, what other specific benefits would you love to enjoy?

Untitled *

How many 8 oz servings of each of the following do you drink each day?
Please also give a brief description of a typical day of eating in breakfast, lunch, dinner

Decaf Coffee *

Alcohol *

COFFEE *

Juice *

Diet Pop *

Water *

When you drink water, is it tyically Bottled, Tap, or Filtered? *

Soda Pop (non-diet) *

Breakfast *

Afternoon Snack *

Lunch *

DINNER *

Other Food Questions

Do you use any artificial sweeteners? (Yes, No, Occasionally) If yes, which one? *

How many times a week do you eat Fast Food? *

How many times per week do you eat Processed Food? *

Do you tend to have cravings? *

What types of food do you crave? *

Do you eat Organic Foods? *

Yes No

Health Conditions

Are you on any prescription medications? *

Yes No

What medical condition(s) are they for? *

Do you have any other medical conditions that you are under a doctor’s care for? *

Do you have any allergies? If so, please describe. *

Have you ever had cancer? If yes, what kind? When? Did you have radiation or chemotherapy? *

With any of your medical conditions, have you ever been told not to eat certain foods or vitamins? (Yes, No) Do you work with any chemicals? (Yes, No) *

Lifestyle and Digestion

Do you currently smoke? (Yes, No) If yes, how many daily? Have you ever smoked? (Yes, No) When did you quit? *

Are you pregnant or nursing? *

Yes No

How many bowel movements do you typically have each day? *

Have you ever had bowel problems? (Yes, No) What was the problem? *

Have you ever had stomach problems? (Yes, No) What was the problem? *

What other nutritional programs or diets have you tried? *

Have you tried cleansing before? *

Yes No

What nutritional supplements are you currently taking (if any)? *

What is your current training or workout routine? How many times per week, how long, how intense etc. *

Let us know...How you see you

What is your highest value in life? *

How would you rate your overall physical health? (Between 1-10) *

Where would you like to be? *

How would you rate your overall energy? (Between 1-10) *

Where would you like your energy to be? *

How would you rate your overall stress level? (Between 1-10) *

Where would you like your stress level to be? *

How would you rate your overall financial health? *

Where would you like your financial health to be? *

From Your Personal Coach

As your coach, I am 100 percent committed to your success. How can I best support you as your coach? *

How would you describe your willingness to be coached / guided to attain these goals? *

High Medium Low

Do you commit to staying in touch with your coach? *

Yes No

Who is part of your Support Team? List the 10 positive people in your life who will want you to succeed. *

What is the best way to reach you? *

Thank you for filling out this Personal Health Survey. Please press submit.

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