Chat with Ashley

NAME

EMAIL

CURRENT WEIGHT

GOAL WEIGHT

AGE

Reason(s) for seeking out a nutritionist + healthy living coach

Have you worked with a healthy living professional (nutritionist, trainer, coach) in any capacity?

If you answered YES to the above: What type + when? What did you achieve? What didn’t you like about previous experiences?

Have you dieted in the past? What diets have you tried + what were the results?

Have you had any dramatic weight gains or losses in the last year? If so, explain below:

Check the boxes of the healthy living practices you have the most trouble with

Meal Planning and prep

Time to grocery shop and cook

Working out regularly

Knowing how to exercise for your specific goals

Stress management

Consistent and quality sleep

What to eat specifically for your goals

How to cook

Overall motivation and accountability

Write your food and drink intake below for the last 3 days

Grocery shopping habits: How often do you go to the grocery store? Do you go with a list? Where do you shop?

List 5 of your top restaurants or food delivery places you order from + write out the menu items you order

Are you willing to commit to meal prep and planning practices?

Yes

No

YOUR DAY: how many meals and snacks do you eat in a day?

Check the boxes of all common feelings you have before +/or after you eat a meal

BEFORE: Overly hungry, famished

BEFORE: Forcing yourself to eat (aka: not hungry)

AFTER: Bloated +/or gassy

AFTER: Overly full (want to unbutton my pants full)

AFTER: Still hungry, unsatisfied (after a decent-sized meal)

BEFORE or AFTER: Headaches

BEFORE or AFTER: Tired, sluggish

Now, think through these answers and try to place what you ate at mealtime if you felt “sick” (nauseous, bloated, gassy…)

Check the box that describes your average day's energy level.

Mostly high energy

Mostly low energy

Up and down throughout the day

If you answered up and down throughout the day above, explain the times of day you are at highest energy and lowest.

Check the boxes of sleeping patterns you have on the average night.

I have trouble falling asleep

I have trouble staying asleep

I get up a lot throughout the night

I wake up still tired

I crave a nap most days

My average night's sleep is less than 6 hours

Describe your weekly workout routine including your workout type, frequency, and duration.

What do you think you would benefit from most when it comes to guidance regarding fitness?

Write down any wellness practices you do regularly. (I.E. light therapy, infrared sauna, meditation or digital detox, detox/salt baths, journaling, massage, et al.)

What are your biggest stressors in your daily life? These can be listed categorically (financial, love life, parenting, work, et al.) or specific/situationally.

On a scale from 1-10, how stressed are you from day-to-day?

When (+ where) do you feel most at peace and balanced?

Who acts as your biggest support system on a daily basis? Will they be on board for healthy living changes?

Check the boxes of any and all of the help you think would help you live healthier.

Receiving pre-made menus with recipes and meal prep tips for the week

Interactive, online group motivational coaching

Food journaling for a professional to review

Help evaluating and redesigning your fitness regimen

Cooking lessons, in any way or specific to meal prep

Weekly one-on-one coaching sessions

24-7 access to a nutritionist, trainer, + chef coach

Eating out and ordering in guidance

What is your ideal budget when it comes to health + wellness services per month?

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