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Essentially Healthy Getting To Know You Survey Version 2
1.
I'd love to know how you specifically found me or who referred you. (Personal referral, video, live event, website, other and please be specific.)
2.
What are your main goals for seeking nutrition counseling with Essentially Healthy?
Support with a specific health condition (i.e. Hashimoto's, etc)
Lose some weight, increase energy, or a general sense of "I'm not feeling as good as I could."
I have been chronically ill for a long time and no one has been able to help me feel better.
I was referred by another practitioner.
Other
Additional comments
3.
Please tell me your first and last name.
4.
Please provide an email for contact (ensure it is correct and check spam/junk for correspondence).
5.
I'd love to know where you are located. If you live within the US, in what state or territory do you live? And what city or town do you currently live in?
6.
Do you have any health or medical conditions that I should know about to help you find the best care? If yes, please explain.
7.
What have you tried so far in order to reach your goal?
Not much, just getting started
I've tried a few things, but I'm overwhelmed by the information out there
I have been to more than 3 practitioners and understanding or relief still feels out of reach
I have completed other Essentially Healthy programs and am interested in diving deeper into my health concerns.
Other
Additional comments
8.
Which of the following items are in your diet in any amount?
Soda
Diet soda
Refined sugar
Alcohol
Fast food
Snack foods (processed chips, pretzels, etc)
Dessert/candies
Gluten
Dairy
Coffee
9.
What percentage of your meals are currently home-cooked?
Less than 25%
25-50%
50-75%
75-100%
10.
Is there any additional information you'd like to share with me in this questionnaire?