Questionnaire (CBT) - Health Coach for Women in Their 40s

Name *

First

Last

Email *

Phone number (with a country code)

Date of birth *

Where do you live? (country, city) *

What is your occupation? *

Height (in cm) *

Weight (in kg) *

Waist and hips circumferences in cm

What is your main problem you would like to solve? *

Your issue story

Do you have any chronic diseases? If yes, please specify. *

Have you had any surgeries, injuries, or serious acute conditions? If yes, please specify. *

Are you currently in a special condition, such as pregnancy or breastfeeding? *

Have you given birth? If yes, how many times?

What supplements do you take constantly? (name, dose) *

Do you take any medicine constantly? If yes please write the name and dose *

Do you have an allergy for any foods or supplements? *

Do you smoke (constantly)? *

How much water approximately do you drink a day? *

How many times a day do you eat? *

Write down here everything you ate yesterday or other usual day (time, what exactly, the amount) *

What is your meal style mainly? (I cook,my wife/husband/partner cook, I eat at the restaurants etc.) *

What is very hard to refuse for you? (for example – sugar, sweets, sausage, beer and so on)

Do you do any sports? If yes – what exacltly and how many times a week? *

Describe your usual day plan (waking up time, work, going to bed time etc.)

If there are any blood tests or other examinations you have , send them on WhatsApp/email

Which source did you hear about me from? *

Comment or Message

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