GILLIAN YOUNG Barkalow
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Health and Nutrition
Night Eating Syndrome
Back
About Gillian
Work with me
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Health Coaching Questionnaire
Night Eating Syndrome Questionnaire
Courses
Ebooks
EBOOKS
Services
Health and Nutrition
Night Eating Syndrome
GILLIAN YOUNG Barkalow
Balanced Wellness Coaching
Testimonials
PRESS
Blog
Work With Me
About
About Gillian
Work with me
New Clients
Health Coaching Questionnaire
Night Eating Syndrome Questionnaire
Name
*
First Name
Last Name
“She/her”, “they/them”, “he/him”, “multiple” or “other”
Nickname or Name you would like to be called by
Email
*
My Goals
*
Age/Height/Weight
Expectations of our coaching together
How can I make you feel safe and comfortable in our coaching together?
Current and past health and physical conditions
Are you on any medication? Do you have any allergies or physical limitations?
How is your emotional wellbeing?
If applicable, how is your period? Do you track it? Is it regular? How is your PMS?
How is your sleep?
What is your dieting history like?
How is your relationship with food and your body?
What does a day in your life look like? What would you love a day in your life to look like?
Current calorie and macro intake if you know:
Have you ever tracked your food intake?
What diets have been successful for you in the past?
Do you have any food allergies, intolerances or dislikes?
What is your biggest challenge with healthy eating?
Are you an all or nothing person or do you prefer to ease into change? Do you want to overhaul your diet?
What do you eat every day that you don’t want to stop enjoying?
Do you have a day or two of the week that you could do a big food prep?
How often do you eat out? Where do you frequent? How does your weekend eating vary from weekdays?
Are you taking any supplements?
Have you been on antibiotics? How many times?
General alcohol and caffeine intake?
Do you eat fast or slow? Do you eat sitting or on the go?
What does a day of eating look like for you? Give times as well.
Do you tend to bloat?
What are your biggest challenges with diet? Are there any bad eating habits you're trying to break?
What are your favourite foods?
How is your emotional wellbeing?
Describe your bowel movements and regularity
Biggest fitness goal and current workout schedule?
How is your workout recovery?
Is your day more sedentary or do you stand/walk often?
Do you have access to a gym? Are you interested in gym workouts? What kind of cardio do you like?
How would you rate your stress levels, 1-5, 1 being chill & 5 being very stressed? (Be mindful to take in emotional, physical, mental stress, cultural or social stress)
How do you usually manage stress?
How can I best support you?
Thank you!