Contact – Grounded

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HI@GROUNDEDNWA.COM

1210 SE WALTON BLVD, BENTONVILLE AR 72712

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Complete the form below to get started on your FREE initial Health Coaching Assessment!

What is your preferred method of initial contact?

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Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)

Describe where you would like to be in your Health...

Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.)

When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?

Are you pregnant?

Yes No

Are you nursing?

Yes No

If yes, how old is your baby?

Are there any food or other allergies that I should be aware of?

Are you taking other medications or have other medical conditions that could influence which program we choose?

How many hours of sleep do you typically get?

What time do you typically go to bed?

What time do you typically wake up?

How is your quality of sleep?

Do you wake up feeling rested?

How much water do you drink each day?

How much Coffee?

How much Soda?

How much Tea?

How much Alcohol

How would you rate your energy level? (on a scale of 1-10)

How many times a week do you exercise?

What physical activities do you participate in?

Are there things you can't do that you would like to be able to?

How would you rate your stress level? (on a scale of 1-10)

What do you do for work?

How much do you enjoy what you do?

Are there other stressors in your life?

How many meals per day do you eat?

When do you eat your first meal?

When do you eat your last meal?

Do you snack between meals?

What kind of snacks?

How many times a week do you eat out?

Where?

Current Weight

Height

Have you tried to lose weight before?

What has been most difficult about losing/maintaining weight in the past?

How healthy would you rate your surroundings? (on a scale of 1-10)

Do you have healthy & active friends, supportive family, keep junk food in the house, etc?

Is there anyone in your life who would like to get healthy with you?

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