Kate Weiland Health, Weight, Nutrition Coach Ask Kate weiland about 3 Day Nutrition Trial
Phone: (916) 903-8335
Email:
info@kateweiland.com
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Kate Weiland Wellness Profile 

Kate Weiland Health CoachThank you for your interest in our wellness profile questionnaire. Coach Kate would LOVE to hear from you.

 

Please complete the form and then click "Submit" to send.


 Please complete ALL fields in order to send the profile.
 
Personal Details  
 Name (first and last) Facebook Name
 
 Email Telephone (including area code)
 
 Address (Street, City, State, Zip)  
 
Gender (female or male) Age (years)
   
Height (FT IN)  Weight (LBS) 
   
Who is your coach?  Who referred you, if not your coach? (may be blank)
   
Health Questions  
1. How many pounds would you like to lose/gain, or what is your health goal?
2. What have you tried before and why did it not work for you?
3. Do you eat three meals a day? (yes or no)
If no, which meals do you skip?
4. Do you snack? If yes, what do you snack on?
5. How many times during the week do you eat out?
6. How much water do you drink daily?

What else do you drink? (tea, juice, soda, coffee, energy drinks 
7. When are you most tired?
8. When are you most hungry?
9. What time do you wake up and go to bed?
10. What physical activity / workouts do you do now?
11. What do you typically eat for breakfast and what time? 
12. What do you typically eat for lunch and at what time? 
13. What do you typically eat for dinner and at what time? 
14. Where do you work and what are your work hours? Do you have any restrictions for breaks while at work?
15. Do your days off from work wake hours and eating habits look different? If so, what changes with your eating habits?
 Any additional Information  
 
   
 * Spam Protection. Enter the word Health (case sensitive).
   
   
 
Notes:

1. Information sent via this form through the Internet is not secure. Do not use the form to send us confidential or sensitive information.

2. Your email message is not private in that it is subject to review by our employees.

Contact Us

You may also contact our office by:
P: (916) 903-8335
E:
info@kateweiland.com

 

 

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