90 Day Deep Dive Questionnaire

Name

Email

Address

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

Day Phone

Evening Phone

Mobile Phone

Date of Birth

Marital Status

Occupation

Number Of Children & Age(s)

Referred By

Medical History

Please check if you have any of the following. Explain any “YES” answers below as needed.

LIST MEDICATIONS, VITAMINS & HERBAL PREPARATIONS.

WHAT ARE YOUR BIGGEST CHALLENGES RIGHT NOW?

WHAT HAVE YOU TRIED BEFORE?

WHAT IS THIS PROBLEM COSTING YOU?

HOW IMPORTANT IS CHANGING THIS ISSUE FOR YOU?

Weight History

Height

Current Weight

Desired Weight

Lowest Weight In Past Year

Highest Weight In Past Year

Do You Want To Lose/Gain/Maintain Weight?

If Applicable, When (And How) Did Your Weight Gain Or Weight Loss Begin?

For Weight Loss Clients

Tell Me Why You Want To Lose Weight

List Latest Lab Values, If Available and Date

Vitamin D Level

Thyroid TSH Level

Total T4 Level

Anti-Thyroglobulin AB

T3 Free Level

Hb-A1c Level

T4 Free Level

Celiac Test Results

Bowel Habits

Frequency

1 – 3 X Day
More Than 3 X Day
Not Regularly Everyday

Do You Experience Excessive Intestinal Gas?

Yes
No

Exercise History

Do you exercise?

If no, why?

Type of exercise

How often?

For how long?

Describe Other Physical Activities

What Kinds Of Circumstances Interfere With Physical Activity?

Choose The Best Description Of Your Energy Level

Usually energetic/occasionally tired
Average energy/sometimes more energetic/sometimes more tired
Frequently tired/occasionally energetic
Always tired/no energy

Sleep & Stress Habits

How Many Hours Of Sleep Per Night (On Average)

Is Your Sleep Restful?

Yes
No

How Do You Cope With Stress In Your Life?

Food Choice Inventory

Food Dislikes

Food Allergies/Intolerances

Meal Planning

How Many People In Your Household?

Who Plans Meals?

Who Cooks?

Who Shops?

Is A Shopping List Used?

Dining Out

How Often Do You Eat Out Each Week?

What Meals?

Where?

How Many Times Each Week Do You Eat At A Fast Food Restaurant?

Where?

Beverages

Do You Drink Alcohol?

Yes
No

Types

Weekly Amount

Do You Drink Coffee/Tea?

Yes
No

Regular Or Decaf?

Daily Amount

Other Beverages?

Daily Amount

Food Habits

Do You Skip Meals?

If Yes, What Meals And Why?

Do You Crave Certain Foods?

What? / When?

Do You Eat Before Bedtime?

What?

What Do You Feel Are Your Worst Eating Habits?

What Is Your Current Diet Like? List What You Generally Eat For:

Breakfast

Lunch

Dinner

Snacks

Beverages

Also, List Approximate Times You Eat:

Breakfast

Lunch

Dinner

Snacks

Do you eat when you are:

Allergy History

Do You Have Any Known Food Or Environmental Allergies?

List All Foods, Additives, And Medications That You Know Or Suspect You Are Allergic To:

DO YOU HAVE ANY EXPECTATIONS FROM SPEAKING WITH CAITLIN OR SPECIFIC THINGS YOU HOPE TO GET OUT OF OUR TIME TOGETHER?

PLEASE TELL ME 5 THINGS YOU LOVE ABOUT YOUR LIFE!

ANYTHING ELSE YOU WOULD LIKE ME TO KNOW?

Thank you! Congratulations on your commitment to better health. I look forward to serving you.

All information is kept strictly confidential and I will never share it with anyone.

If you have any questions, I encourage you to contact me using the Contact form link above after you click Submit. You will be receiving an email from me shortly after you submit your form so please be on the lookout for that. Once you click submit, you will be directed to a page where you can sign up for your first session. Exciting!!

Talk with you soon,
Caitlin

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