11. If you use Facebook, what is your Facebook name (so we can connect on social media)?

15. In your current roles (in business and in life), how many people a day would you say you support/lead/cheer on/lift up? *

1-5

6-10

11-25

26+

16. How do you fill your own cup (self-care/health/wellness)? If you currently do not, how would you like to take better care of yourself? *

21. How are you connected to this number? (eg: was this weight before kids, at this weight I felt strong and healthy etc) *

22. Current Daily activity *

Sedentary - Sitting at the computer most of the day, or sitting at a desk

Lightly active - Light industrial work, sales or office work that comprises light activities

Moderately active - On your feet comprised of moderate activity (eg: Cleaning, kitchen staff, or delivering mail on foot or by bicycle.)

23. Current Workout Activity *

Sedentary - No working out

Lightly active - Low intensity aerobics

Moderately active - High intensity aerobics or weight training

Very active - Weights 3+/week + aerobics

Extremely active - 2+ hrs/day and athletes

25. In general, what are your goals? Write down ALL the goals from above that apply. *

26. Please list all of your concerns about your health, eating habits, fitness and/or body *

27. Out of those concerns listed above, which one(s) feel most important or urgent? *

31. How would you like your lifestyle and wellness to be different? *

32. On a scale of 1 to 10, with 1 = not willing at all and 10 = extremely willing, how willing are you to significantly modify your diet? *

33. On a scale of 1 to 10, with 1 = not willing at all and 10 = extremely willing, how willing are you to engage in regular exercise/activity? *

34. How many days would be ideal to participate in a structured movement program? *

Ad hoc because I don't have a consistent schedule

2 days per week

3 days per week

4 days per week

5 days per week

6 days per week

7 days per week

35. On a scale of 1 to 10, with 1 = not willing at all and 10 = extremely willing, how willing are you to keep a record of dietary intake, physical activity and weight? *

36. On a scale of 1 to 10, with 1 = not willing at all and 10 = extremely willing, how willing are you to alter your work and home environment (e.g. remove or reduce accessibility to treats in the kitchen/at your desk)? *

37. On a scale of 1 to 10, with 1 = not willing at all and 10 = extremely willing, how willing are you to practice relaxation techniques on a regular basis? *

38. On a scale of 1 to 10, with 1 = not willing at all and 10 = extremely willing, how willing are you to improve your sleep habits? *

39. On a scale of 1 to 10, with 1 = not willing at all and 10 = extremely willing, how willing are you to take nutritional and/or herbal supplements each day? *

40. On a scale of 1 to 10, with 1 = not willing at all and 10 = extremely willing, how willing are you to connect with a coach regularly to assess your progress? *

41. With guidance and support, on a scale of 1 to 10, with 1 = not confident at all and 10 = extremely confident, how confident are you in your ability to follow through on the above activities? *

42. What challenges do you anticipate will impact on your journey to creating sustainable wellness (e.g. long work hours, lack of social support, child care, motivation etc)?

43. Is anyone else involved in your decision-making when it comes to how you choose to improve your lifestyle? If so, please briefly detail.

46. What is your previous training experience? Please type "none" if you have not trained before. *

48. Have you tried anything in the past to change your habits, your health, your eating and/or your body? If so, what?

49. Which of those things worked well for you? (Even if you might not be doing them now)

51. If you could improve your health in 3 ways, what would they be?

52. Have you been diagnosed (currently or in the past) with any significant medical condition and/or injuries? *

Yes

54. Right now, do you have any specific health concerns such as illnesses, pain, and/or injuries? *

Yes

56. Are you currently taking any prescription or over the counter medicines? *

Yes

57. If yes, please list dosage, strength, frequency and what it's treating

58. Do you suffer from any of these:

Allergies

Asthma

Heart disease

Any other condition that can be aggravated by heat and humidity?

59. Do you experience any digestion issues (diarrhoea, constipation, bloating, reflux, heartburn etc)? If so, please detail.

61. Have you ever been hospitalised for a fall in the past 12 months?

Yes

62. On a scale of 1-10, how do you rank your health right now? (where 1=Horrible and 10=Awesome) *

64. Using the same scale, how would you rate your energy levels? *

67. Do you fall asleep straight away or does it take a while? *

Straight away

Takes a while

69. Do you wake the same time each day, even when you're on holidays?

71. What time do you first eat or drink something once you've woken up? *

74. What time do you normally have this snack? (If not applicable, type N/A) *

78. What time do you normally have this snack? (If not applicable, type N/A) *

80. What time do you normally eat dinner? (If not applicable, type N/A) *

83. Do you like the idea of following a meal plan to help you stay accountable for your daily food intake? *

Yes

84. Do you like the idea of using a mobile app to scan food barcodes and/or log your food intake manually to help you stay accountable about what you eat? *

Yes

85. On a scale of 1-10, how would you rate your stress levels? (where 1=Chilled and 10=Very Stressed) *

87. If you drink coffee, how do you have it and how many do you have per day?

89. On a scale of 1-10, how committed are you to yourself and change? (where 1= I'm Not and 10=I'm All In!) *

90. By signing this form, you believe that to the best of your knowledge, all of the information you have supplied within this form is correct. *

Yes