Inflammation Reset PREMIUM Onboarding - Simple Smart Science Coaching Program

Name: *
Email: *
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Demographics:

Name

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Current Age

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State/Country in which you reside

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Occupation (if retired what was your former occupation if you had one)

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Relationship Status

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Weight

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Ideal weight

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Coaching Questions:

What are 3-5 health/wellness/lifestyle goals you would like to achieve?

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Client Wisdom: What do you ALREADY KNOW that you should or should not be doing in order to support your brain health?

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What RESOURCES do you have in your life to support you in achieving your goals? (e.g. individuals, support groups, communities, programs, tools, training, therapists, etc.)

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What is your biggest fear?

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Personal Health:

On a scale of 1 - 10, how much stress do you feel you experience regularly?

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What are the main causes of stress?{"type":"textarea","name":"__generic21","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}

Are your currently pre-diabetic or Diabetes? If yes, Pre, Type 1 or Type 2 and for how long?

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Are you currently or have you been a smoker? If yes, for how long?

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Other Major Health Conditions:

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Do you experience major anxiety? Describe frequency and severity.

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Do you experience major depression? Describe frequency and severity.

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Current Medications - Rx AND Regular Use Over the Counter (ie. anti-histamines, Advil, etc...)

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Prior Long-Term Use Medications{"type":"textarea","name":"__generic37","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}

List your current herbs and/or nutritional supplements (dosages NOT necessary):

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Do you have a Functional/Integrative/Holistic Medicine doctor? if so, for how long?

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Do you have a primary care physician? If yes, how often do you see him or her?

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Do you see any other health care providers? For example: Chiropractor, Massage Therapist, Herbalist, Acupuncturist, Psychotherapist, Nutritionist? If yes, how long have you been seeing them?

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How would you rate your overall HAPPINESS/JOY level?

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How much do you agree with this statement: "I believe it is within my power to control my future cognitive health outcomes."

1 = Strongly Disagree 2 = Disagree 3 = Neutral / Average 4 = Agree 5 = Strongly Agree{"type":"radio","name":"MemoryRecallAbility5","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one of the above options.","options":"1 = Strongly Disagree\n2 = Disagree\n3 = Neutral / Average\n4 = Agree\n5 = Strongly Agree"}

How would you rate your self-esteem/self-confidence?

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PILLARS OF BRAIN HEALTH QUESTIONS

Diet:

Are you:

Vegetarian Vegan Pescatarian Carnivore{"type":"checkbox","name":"__generic45","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Vegetarian\nVegan\nPescatarian\nCarnivore"}

Describe in detail your typical diet, and the general timing of each meal.

Breakfast

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Lunch

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Dinner

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Snacks

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How much water do you drink each day and from what source?

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Describe your typical beverage choices and quantity per day or week:

Coffee yes no{"type":"checkbox","name":"__generic55","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"yes\nno"}

Quantity

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Alcohol

yes no{"type":"checkbox","name":"__generic57","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"yes\nno"}

Quantity

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Soda

yes no{"type":"checkbox","name":"__generic59","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"yes\nno"}

Quantity

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Fruit juice
yes no{"type":"checkbox","name":"__generic61","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"yes\nno"}

Quantity

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Other

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Do you seek out organic foods?

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Describe your intake of healthy fats (i.e. fish, fish oils, olive oil, nuts/seeds, avocado, olives...)

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Do you crave sugar or carbs? If so, what do you indulge in and how often.

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Do you like to cook?

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Inflammation:

Do you have a diagnosed gut disorder, e.g. IBS, IBD, SIBO, leaky gut, colitis, other?

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Have you ever tested positive for a food allergy or sensitivity? If yes, what are you allergic or sensitive to?

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Do you experience regular bowel movements?

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Do you experience frequent heartburn?

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Do you regularly experience bloating after meals?

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Exercise:

Do you have an exercise routine? Please describe.

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What forms of exercise would you like to engage in that you aren't currently?

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Do you have any physical limitations to movement/exercise?

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Sleep:

On average, how many hours of sleep do you get each night?

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What time do you generally go to sleep and wake up?

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Do you typically wake in the night? How often? Do you have trouble getting back to sleep?

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How do you generally feel upon waking? (physically, mentally, emotionally)

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Please describe your energy throughout the day.

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Do you have any diagnosed sleep disorders? (sleep apnea, night terrors, narcolepsy, sleep walking, etc.)

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Do you snore? Yes No Sometimes Not sure{"type":"checkbox","name":"__generic91","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\nNo\nSometimes\nNot sure"}

Do you sleep alone?

Yes No Sometimes Not sure{"type":"checkbox","name":"__generic92","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\nNo\nSometimes\nNot sure"}

Do you wake up with a dry mouth

Yes No Sometimes Not sure{"type":"checkbox","name":"__generic93","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\nNo\nSometimes\nNot sure"}

Do you find yourself mouth breathing throughout the day?

Yes No Sometimes Not sure{"type":"checkbox","name":"__generic94","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\nNo\nSometimes\nNot sure"}

How many hours of screen time (tv, computer, phone, tablet) do you average per

day?

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How much sunlight are you exposed to daily?

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Stress Reduction:

What tools or practices do you use to lower your stress level when it rises?

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Do you have experience with breathwork and/or meditation? If so, please describe.

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Do you pray or have other spiritual practices?

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How much time do you spend in nature?

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What are your favorite self-care practices? These are things that you do regularly to treat yourself kindly and 'nourish' your body and mind when NOT in crisis - for examples: hot baths, calling friends, massage, sauna, walks, listening to music, aromatherapy, journaling, etc...

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Social/Purpose:

Describe your current social life?

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What gets you out of bed each day and/or what gives you a sense of purpose?

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What do you consider your strengths? talents? gifts?

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What do you consider your weaknesses?

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Use It or Lose It:

Do you feel that you challenge your brain on a regular basis? How? (e.g. work, learning new things, games)

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Last but not least:

How do you hold yourself accountable? (e.g. calendar, phone reminders, partner, notes, etc.)

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How willing are you to take action and make changes in your lifestyle in order to achieve your goals?

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Do you like to celebrate, treat or reward yourself for your accomplishments and hard work completed? If yes, what are your favorite ways to do so?

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