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Strategy Intake
Contact information
Name
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Pronouns
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Other (if you're comfortable, specify in the last question of the form!)
Date of birth
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Phone number
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Email
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Occupation
Medical history
Are you taking any medications or health supplements? If you’re comfortable, please specify type and reason for taking.
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Do you have any allergies?
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Have you ever experienced any problems with sleep? If yes, please explain.
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Have you ever experienced any problems with digestion? If yes, please explain.
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Do you have any other medical conditions that have not been mentioned that are relevant to your nutrition journey?
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Health & nutrition
What can you tell us about your current nutrition, eating habits and/or fitness?
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Do you currently follow a specific nutrition plan or way of eating? If yes, please explain.
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Have you tried anything in the past to change your habits, health, eating, and/or body composition? If so, what?
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Which of those things worked well for you (even if you may not be doing them right now)?
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Which of those things did not work well for you?
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Do you take part in physical exercise? If so, what and how often?
What degree of stress are you under on a scale of 1-10 (10 being highly stressed)? Why did you choose the answer you did?
Developing your program
What are your nutrition goals (ex: lose weight, gain weight, increase energy, body composition shift or athletic performance?
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How would you like your habits, health, eating and/or body composition to change?
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How long have you been thinking of these goals?
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Realistically, how much time can you dedicate to this process?
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What do you feel are the obstacles that could challenge your journey to your goals?
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Our coaching relationship
What can I do to make this session as valuable as possible for you?
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Do you have any specific questions up front that I should prepare for?
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Anything else you’d like me to know about you? Personality? Needs? Core values? Anything that would help me get a better sense of YOU is totally encouraged here...go wild!
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Consent
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By checking the boxes below, I acknowledge and agree to all terms outlined below.
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Consent
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I agree that Rebel Nutrition shall not be liable or responsible for any injuries to me resulting from my participation and I expressly release and discharge Rebel Nutrition from all claims, actions or judgments as a result of participating.
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Consent
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I understand that Rebel operates on a scheduled appointment basis and that I must provide a minimum of 24 hours notice to reschedule an appointment. Where less than 24 hours notice is given, I understand that I must re-book at my own cost.
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Consent
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I acknowledge that there are no refunds available on this investment.
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Email
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