Full Name *
Email *
Phone *
Age *
Gender *
What is Your Main Goal for This Program? *
How Would You Describe Your Job? *
How Often Do You Consume Alcohol? *
How Often Do You Eat Out? *
How Many Days Per Week Do You Work Out? *
Do You Use Any Fitness Wearable Devices? (i.e. Apple Watch, FitBit, Any Step Tracker) *
How Many Meals Per Day Do You Prefer to Eat? *
What Do You Feel is the Biggest Barrier in Your Wellness Journey? *
Please list any dietary supplements, vitamins, etc. you take:
What Time of Day is Best to Meet with Your Coach? *
Do You Have Any Dietary Restrictions, Food Allergies, or Intolerances? List them: *
Do You Have Any Medical Issues You Want to Share, Celiac Disease, or Diabetes? List them:
Describe What Success Would Mean to You on the My Wellness Coach Program: *
Food Preference Chart – Select the foods you would not like to consume on your My Wellness Coach plan. These are foods that you would prefer NOT to eat on a regular basis. Choose as many as you’d like.
Food Preference Chart - Protein Sources to AVOID (Check the boxes of foods you prefer NOT to eat on a regular basis)
Food Preference Chart - Carbohydrate Sources to AVOID (Check the boxes of foods you prefer NOT to eat on a regular basis)
Food Preference Chart - Fat Sources to AVOID (Check the boxes of foods you prefer NOT to eat on a regular basis)
Food Preference Chart - Vegetable/Fiber Sources to AVOID (Check the boxes of foods you prefer NOT to eat on a regular basis)
Food Preference Chart - Protein + Fat Sources to AVOID (Check the boxes of foods you prefer NOT to eat on a regular basis)
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