Discovery Call Questionnaire

Discovery Form

Please fill in this form with as much detail as you feel comfortable sharing; this enables your coach to come into the Discovery Session knowing as much about you and your goals as possible; so your partnership can begin on the right foot. Your time is valuable, as is ours, so please be honest with your answers so we can serve you towards creating the best possible results in your health, wellness and life.

Name(Required)

First Last

Your best email address(Required)

Phone – Ideally Mobile (Cell)(Required)

If you can use a number that we can WhatsApp that would be great especially if you are outside the UK. This is in case we need to contact you urgently. Please include your country code and area code.

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Current Age(Required)

The reason we ask for this is because our bodies change over time so it helps us to understand where you are on your life journey.

Sex(Required)

Again this helps to understand where your hormones might be.

Male

Female

Taking hormones for sex change

Hormones(Required)

Please explain where you are hormonally – pre menopause, peri menopausal, post menopausal. Have you had a hysterectomy? Are you still menstruating?

How Did You Find Out About Fabulously Keto and Jackie Fletcher?(Required)

Your Way of Eating

How would you describe your way of eating(Required)

Choose the option that best describes your diet

Carnivore – animal products only

Omnivore – animal including meat and plant foods

Pescatarian – fish and plant foods

Vegetarian – including dairy and eggs

Vegan – plant foods only

How much of your diet is processed foods?(Required)

Just a guesstimate of how much of your diet comes from processed food and how much is real food like fresh meat and fresh vegetables/fresh fruit

Health

Please list any underlying health conditions

It is important that your health coach knows of any health conditions.

Health Goals

Why are you reaching out to a health coach today? What specific health, wellness, and lifestyle changes would you like to make? On a scale of 1-10, how important is to you to make each of these desired changes? Where 1 is not important and 10 is an absolute must.

1. Health Goal(Required)

Importance (1-10)(Required)

Please enter a number from 1 to 10.

2. Health Goal

Importance (1-10)

Please enter a number from 1 to 10.

3. Health Goal

Importance (1-10)

Please enter a number from 1 to 10.

4. Health Goal

Importance (1-10)

Please enter a number from 1 to 10.

5. Health Goal

Importance (1-10)

Please enter a number from 1 to 10.

How would your life be different if you were to achieve these health changes?(Required)

Please be as detailed as possible. What would you be able to do and feel?

What have been your barriers in creating these health changes for yourself?(Required)

What have you tried in the past and why hasn't it worked for you? What is stopping you reaching your goals?

How do you feel a Health Coach will help you achieve your goals?(Required)

Coachability Assessment

On a scale of 1-10, rate how ready you are to enter a health coaching relationship right now. 1 = I am not ready 5= I think I’m ready 10 = I am 100% ready and excited!

I am open-minded about learning new ways of eating, moving, and living.(Required)

1-10(Required)

Please enter a number from 1 to 10.

I can commit to changes that feel uncomfortable, unusual, or unconventional.(Required)

1-10(Required)

Please enter a number from 1 to 10.

I will communicate and negotiate with my health coach as an equal partnership, and feel confident to ask for what I need.(Required)

1-10(Required)

Please enter a number from 1 to 10.

I have a high level of self-awareness.(Required)

1-10(Required)

Please enter a number from 1 to 10.

I will keep my word to my coach and to myself.(Required)

1-10(Required)

Please enter a number from 1 to 10.

I understand that health coaching is an investment in myself, and I will not suffer about the financial cost.(Required)

1-10(Required)

Please enter a number from 1 to 10.