Stoked Bodies Client Discovery Form Complete this questionnaire as much as you can so that together we can figure out the right path for you!By doing so you will also be subscribing to our wellness newsletter. Name * First Name Last Name Email * Phone Number Country (###) ### #### GENERAL HEALTH: Please list your main health concerns and include any serious illnesses affecting your health and any medications you are taking. Any serious hospitalizations/injuries/setbacks in the past 5 years? At what point in your life did you feel best? What about that time (habits, emotions, activity, etc) would you like to reconnect with and incorporate into your daily well-being? GENERAL NUTRITION: How would you rate your nutrition? Is your Nutrition excellent? Strongly Disagree means you have Poor nutrition and Strongly Agree means you have Excellent Nutrition Strongly Disagree Disagree Neutral Agree Strongly Agree Please select the reasons you eat (besides hunger). Stress Depression Boredom Happiness Habit Annoyance Other if you have checked "other" in the previous question, please state the other reasons below: What percentage of your food is home-cooked? Are you interested in cooking at home more? Yes No Please list all foods and beverages that you need to AVOID due to intolerance, preference, 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? SWEETS / SUGAR CARVINGS: In this section, "Sweets" can be any processed or natural carbohydrates that convert to sugar in your system such as pasta, bread, candy, desserts, cookies, crackers, chips, soda, ice cream, pizza, cereals, potatoes, and rice (to name a few). In the past 12 months have you ever eaten more sweets than you intended to? Yes No In the past 12 months have you ever neglected some of your usual daily responsibilities due to eating sweets? Yes No In the past 12 months have you felt that you wanted to cut back on eating sweets? Yes No In the past 12 months has anyone objected to you overeating sweets or to your eating habits in general? Yes No In the past 12 months have you ever found yourself preoccupied with wanting sweets or found yourself thinking a lot about sweets? Yes No In the past 12 months have you ever used sweets to relieve emotional discomfort, such as fatigue, irritation, sadness, anger, tiredness, boredom, etc? Yes No PHYSICAL ACTIVITY: How often do you exercise per week currently? What types of exercise do you do on a regular basis? Have you had any injuries or surgery that require specialized training and rehabilitation? 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? How do you see yourself in a year and how would you like to feel? What changes would you like to make 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 No Are you interested in a shorter term goal or a longer term transformation? Shorter Term Goal Long Term Transformation If you chose "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? 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’ve felt in past attempts to change your health? Do you perceive any barriers to your desires to make a change? How ready are you to make changes? Very Ready Somewhat Ready Not Ready Coaching Package Options: Please choose the coaching package that best suits you: Fitness Coaching Only Nutrition Coaching Only Fitness & Nutrition Coaching Bundle For Fitness Coaching Only, please choose the option that best suits you: 3-Months: $1,200 ($400/mo) 6-Months: $2,250 ($375/mo) - $150 Savings! 12-Months: $4,200 ($350/mo) - $600 Savings! For Nutrition Coaching Only, please choose the option that best suits you: 3-Months: $1,200 ($400/mo) 6-Months: $2,250 ($375/mo) - $150 Savings! 12-Months: $4,200 ($350/mo) - $600 Savings! For the Fitness & Nutrition Coaching Bundle, please choose the option that best suits you: 3-Months: $2,100 ($700/mo) 6-Months: $4,050 ($675/mo) - $150 Savings! 12-Months: $7,800 ($650/mo) - $600 Savings! Payment Options: Preferred method of payment: Credit Card (additional 3% service fee) Venmo 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. Based on the package option I chose above, I agree to pay the corresponding fee upon receipt of payment request from Trish Keefer through the chosen method of payment. I understand that services will commence once payment has been received by Trish Keefer. Date * MM DD YYYY Thank you for your submission, we will review the information you have provided and will contact you shortly. In the meantime if you have any questions, please feel free to contact us by email at trish@stokedbodies.com or by calling us at 858-422-1975. Have a wonderful day!
