Disprove your inner critic, today!
If you're doubting yourself, you're in the right place. This is your opportunity to step out of your own way. I will be there with you each step of the way to help you to uncover what is holding you back. Together we will develop a framework to inspire you to play the best game of your life.

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Yes!
 
What's your first name? *

 
Hey {{answer_djlK5QfSKkLI}}, nice to meet you.
What's your last name?

 
{{answer_djlK5QfSKkLI}}, what is your number?

 
{{answer_djlK5QfSKkLI}}, what is your date of birth?

 
{{answer_djlK5QfSKkLI}}, what is your postcode?

 
ENERGY

{{answer_djlK5QfSKkLI}}, are you happy with your current energy level?
     
 
ENERGY BOOSTERS

What are the energy boosters in your life?

 
ENERGY DRAINS

What are the energy drains in your life?

 
How important is it that you make changes or improvements in your energy level at this time?

Please rate the importance on a scale of 0 to 10
 
How confident are you that you can make changes or improvements in your energy level at this time?

Please rate your confidence on a scale of 0 to 10
 
SLEEP AND STRESS

{{answer_djlK5QfSKkLI}}, are you feeling stressed or tired?
     
 
Do you get 7-8 hours of sleep at night?


 
Do minor problems throw you for a loop?


 
Do you find it difficult to get along with people you used to enjoy?


 
Are you unable to stop thinking about your problems?


 
Do you feel frustrated, impatient, or angry most of the time?


 
Do you experience feelings of tension and anxiety?


 
Do you feel calm and peaceful?


 
Do you have a lot of energy?


 
Are you a happy person?


 
Do you take the time to relax and have fun daily?


 
Do you feel worthless, inadequate, or unimportant?


 
Are you coping well with your current stress load?

     
 
Do you have friends and/or family with whom you can share problems and get help if needed?

     
 
Have you suffered a personal loss or misfortune in the past year?

(For example: a job loss, disability, divorce, separation, or the death of someone close to you).
     
 
How important is it that you make changes or improvements in your sleep and stress level at this time?

Please rate the importance on a scale of 0 to 10
 
How confident are you that you can make changes or improvements in your sleep and stress levels at this time?

Please rate your confidence on a scale of 0 to 10
 
LIFE BALANCE

{{answer_djlK5QfSKkLI}}, does your life feel balanced?
     
 
Do you maintain a comfortable balance between Work, Family, Friends and Self?


 
What area would you like to have more time for?


 
How ready are you to make changes or improvements in your life balance at this time?

Please rate your readiness on a scale of 0 to 10

 
How important is it that you make changes or improvements in your life balance at this time?

Please rate the importance on a scale of 0 to 10

 
How confident are you that you can make changes or improvements in your life balance at this time?

Please rate your confidence on a scale of 0 to 10

 
WEIGHT

{{answer_djlK5QfSKkLI}}, are you happy with your current weight?
     
 
What is your current weight?

 
What was your weight 2 years ago?

 
What was your weight 5 years ago?

 
Have you utilized any weight-management program(s) in the last 10 years?

If yes, please describe
 
How important is it that you make changes or improvements in your weight at this time?

Please rate the importance on a scale of 0 to 10
 
How confident are you that you can make changes or improvements in your weight at this time?

Please rate your confidence on a scale of 0 to 10
 
EXERCISE

{{answer_djlK5QfSKkLI}}, would you like to make changes or improvements in your level of exercise?
     
 
How many day/s per week do you do aerobic exercises?

At least 20 minutes of vigorous intensity activity (fitness walking, cycling, jogging, swimming, aerobic dance, active sports) OR at least 30 minutes of moderate intensity activity.
 
How many day/s per week do you do strength exercises?

At least 10 minutes of strength-building exercises (such as sit-ups, push-ups, or use strength-training equipment).
 
How many day/s per week do you do flexibility or stretching exercises?

At least 5 minutes to improve flexibility of your back, neck, shoulders, and legs.
 
Do you currently have any limitations on physical activity?

For example injuries, illness, medical conditions. If yes, please specify below:
 
Have you previously had any limitations on physical activity?

For example injuries, illness, medical conditions. If any, over the last 5 years, please specify below:
 
How important is it that you make changes or improvements in your level of exercise at this time?

Please rate the importance on a scale of 0 to 10

 
How confident are you that you can make changes or improvements in your level of exercise at this time?

Please rate your confidence on a scale of 0 to 10
 
NUTRITION

{{answer_djlK5QfSKkLI}}, would you like to make changes or improvements in your nutrition?
     
 
Do you eat a full breakfast each day?


 
Do you eat “junk” snack foods between meals?

Some examples: chips, pastries, candy, ice cream, cookies.

 
Do you eat high fat food?

Some examples: hamburgers, hot dogs,  cream, cheese, whole milk, eggs, butter, cake, pastry, ice cream, chocolate, fried foods, and many fast foods.

 
Do you eat low fat food?

Some examples: lean meats, skinless poultry, fish, skim milk, low fat dairy products, fruit desserts, vegetables, pasta, legumes (peas and beans).

 
Do you eat refined grain?

Some examples: white bread, rolls, regular pancakes and waffles, white rice, typical breakfast cereals, typical baked goods.

 
Do you eat whole grain?

Some examples: whole grain breads, brown rice, oatmeal, whole grain or high fiber cereals.

 
Do you eat 5 servings of fruits and vegetables daily?


 
Do you drink eight 8 glasses of water daily?


 
Do you drink non-diet soft drinks daily?


 
How many alcoholic drinks do you consume per week day?

 
How many alcoholic drinks do you consume per weekend?

 
How important is it that you make changes or improvements in your nutrition at this time?

Please rate the importance on a scale of 0 to 10
 
How confident are you that you can make changes or improvements in your nutrition at this time?

Please rate your confidence on a scale of 0 to 10
 
HEALTH

{{answer_djlK5QfSKkLI}}, would you like to make changes or improvements in your health?
     
 
In general, is your overall health excellent?

     
 
Do you have a primary care doctor who you see regularly?

     
 
Has your doctor informed you of any health concerns you need to be aware of?

If yes, please specify
 
Do you have high blood pressure?

     
 
Do you use drugs or medicines?

(Include prescription and non prescription) that treat depression, affect you mood, help you relax, or help you sleep.

 
Have you had bodily pain during the past month.


 
During the past month, have you had difficulty doing work, or other regular activities, as a result of your physical health?


 
Do you smoke?


 
Are you pregnant


 
Do you have glaucoma?

     
 
Have you missed from work due to illness or injury during the last 6 months?

If yes, please specify amount of days and describe
 
What is your biggest challenge with regards to your health?

Please include as much detail as possible
 
How important is it that you make changes or improvements in your health at this time?

Please rate the importance on a scale of 0 to 10
 
How confident are you that you can make changes or improvements in your health at this time?

Please rate your confidence on a scale of 0 to 10
Thank you for taking the time to answer these important questions.
I will be in contact soon.
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