1. Name
*
2. Email Address
*
3. Phone Number
*
4. What is your age?
5. What are your current health goals that you would like to achieve?
6. Why do you want to improve your health at this time? What is your current motivation to improve your health at this time?
7. On a scale from 1-10, how committed & motivated & willing are you to making some radical lifestyle changes that will ultimately be indulgent, fun, and rewarding?
8. What are your biggest health challenges?
9. What is your height?
10. What is your current weight?
11. What is your ideal weight?
12. What have you done in the past to try to lose weight, and what was the outcome?
13. Do you have any dietary restrictions or allergies?
14. What medications & vitamins are you currently taking?
15. What foods do you love to eat?
16. Any foods that you hate to eat?
17. What sorts of drinks do you drink and how frequently?
(Water, juices, sodas, coffees, teas, smoothies, shakes, beer, wine, liquor, etc.)
18. Please tell me a little bit about your current diet and your current eating habits.
19. Focusing on your carb intake, how much do you eat fruit, sugar, and grains?
20. How much do you use your kitchen? Do you like to cook or bake?
21. How often do you dine out and where?
22. What do you eat for snacks and desserts?
23. Do you have any health issues or digestive issues?
Please share any health issues that you would like to improve, including gut issues and bowel movements.
24. Have you had any major surgeries?
25. On a typical day, what times do you eat your meals, snacks, and drinks?
26. When was the last time you fasted and how long was it for?
27. What is your current exercise regimen?
28. How much do you know about the keto lifestyle?
29. Do you have any initial fears or concerns about the keto lifestyle?
30. What would make this coaching relationship extraordinary for you?
31. Any initial questions that you would like to ask me, or anything else that you would like to share with me?
32. What is your city, state, and zip code? (In case I have restaurant & grocery shopping recommendations for your area.)
33. What grocery stores do you normally shop at?
34. How did you hear about my keto health coaching?
35. Can I share before & after photos of you on my website?
36. Please agree or disagree with this statement:
*
Scott Rose is not a doctor. You should always seek the advice of a physician or other qualified medical provider with any questions you may have regarding a medical condition. Scott Rose is not giving medical advice. Scott Rose's keto health coaching programs are for educational purposes only. If you make any changes to your lifestyle or if you are taking any medication, please consult with a physician first.
