Full Name *

Email *

Phone

Age

Gender

Height (example 5 ft, 7 in)

Current Weight (lbs)

GENERAL HEALTH

Please list your main health concerns & include any serious illnesses affecting your health and any medications you are taking:

Any serious hospitalizations/injuries/setbacks in the past 5 years?

GENERAL NUTRITION

How would you describe your nutrition choices based on the examples below?

Excellent! I have a well balanced diet and eat mostly whole foods.

Good! My diet is fairly well balanced and I eat a good amount of whole foods & a few packaged/convenience foods.

Average. I'm not sure if my diet is well balanced. I also tend to eat an equal amount of whole foods & packaged/convenience foods.

Needs Work. I eat more packaged/convenience foods than whole foods and want to learn how to change that.

Poor. I eat only packaged/convenience foods and want to learn how to incorporate whole foods and have a more balanced diet.

If you chose "Other" type it below

What percentage of your food is home-cooked?

Are you interested in cooking at home more?

Yes

Please list all foods and beverages that you need to AVOID due to intolerance, preference, etc. Please be specific (eg. gluten, dairy, soy, etc).

What time do you eat breakfast and what do you typically eat? Please indicate if meals are prepared at home or if you are eating out and how those differ.

What time do you eat lunch and what do you typically eat? Please indicate if meals are prepared at home or if you are eating out and how those differ.

What time do you eat dinner and what do you typically eat? Please indicate if meals are prepared at home or if you are eating out and how those differ.

What time (and how often) do you eat snacks and what do you typically eat?

What liquids do you drink?

PHYSICAL ACTIVITY

How often do you exercise per week currently?

What types of exercise do you do on a regular basis?

Aside from injuries or surgery, do you experience any additional restrictions to your mobility? If so please describe in detail and include any treatment you are currently receiving.

What’s one activity you want to be able to do in one month’s time?

What’s one activity you want to be able to do in six month’s time?

PATH TO SUCCESS

What do you feel good about in your life right now?

What is your vision for yourself? and How do you see yourself in a year and how would you like to feel?

What changes would you like to make in order to achieve your vision?

How would you describe your health journey up to this point?

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

Yes

Are you interested in a short term or a long term transformation?

Short Term Goal

Long Term Transformation

If you chose the "Long term transformation," describe your long-term goals in detail including the positive outcomes you desire as a result of health coaching? (Some examples include: weight loss, diminished cravings, better sleep, more energy, reduced pain and inflammation, enhanced mood, reduced brain fog, improved athletic performance, etc.)

What do you hope for in a coaching relationship? and Where do you feel you need the most support and accountability?

What is motivating you to pursue health coaching? What is your WHY? This is a very important step so please dig deep on this one because your overall success will depend on it.

Does this motivation differ from what you have felt in the past attempts to change your health?

Do you perceive any barriers to your desires to make any changes?

How much ready are you to make these changes?

I'm Ready

Somewhat Ready

Not Ready

COACHING OPTIONS

Please choose the program duration that best meets your needs:

3-Months (My digestion, hormones, sleep, and fitness levels are all quite good and/or I am only looking to change my weight by 8 pounds or less)

6-Months (My digestion, hormones, sleep, and fitness levels need some help and/or I am looking to change my weight by 10-15 pounds)

12-Months (My digestion, hormones, sleep, and fitness levels need an overhaul and/or I am looking to change my weight by 15 or more pounds)

I'm not sure

PAYMENT OPTIONS

Preferred method of payment:

Pay Monthly via Credit Card (additional 3% service fee)

Pay Monthly via Venmo

Pay in Full & Save

Not Sure Yet

RELEASE and ACKNOWLEDGEMENT

Release & Acknowledgement *

I hereby acknowledge that the information I've given above is complete and accurate. I understand that Trish Keefer/Stoked Bodies does not intend to diagnose, treat, prevent or cure any disease or condition, make any medical claims and/or advice that would substitute for my personal physician’s care. I understand that the minimum commitment for Stoked Bodies coaching is 3 months and I agree to pay the corresponding monthly fee upon receipt of payment request from Trish Keefer through my chosen method of payment (credit card or Venmo). I understand that services will commence once payment has been received by Trish Keefer.

Agreement Date

I consent to receive non-marketing text messages about account notifications, alerts, order confirmations, from Stoked Bodies. Message frequency may vary, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

I consent to receive marketing text messages, about special offers, discounts, and service updates, from Stoked bodies, at the phone number provided. Message frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

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