Evolution Wellness Change Your Mind About Your Body Program Questionnaire
Please answer all of the questions below to help me tailor your program to fit your needs. All
of your information is strictly confidential.
Name:
Street Address:
City/Town
State/Province
Country:
Email:
Phone number:
1) Do you struggle with negative self-talk about your body? What types of things do you
say to yourself?
2) Do you avoid social situations because you feel that you have nothing to wear or will be
self-conscious about your weight or body?
3) Do you know how the Law of Attraction works (meaning, do you know that how you feel
and what you focus upon indicates what you’re manifesting?)
4) How much weight do you feel you’d need to lose before you could appreciate or love
your body?
5) Can you possibly imagine feeling good about your body before your body changes?
6) Have you ever lost weight in past? Tell me about it. How much did you lose? How did
you do it? How long did it last? Was it hard? If you gained it back, why?
7) Why do you believe losing weight is hard for you? In other words, what are the
problems for you? Do you overeat? Do you eat the wrong things? Do you struggle with
food addiction or cravings? Do you have a slow metabolism?
8) Are other people in your family overweight?
9) How long have you been struggling with weight and/or body image issues?
10) What happened the last time you were at your ideal weight?
11) Do you try to follow any sort of healthy eating plan now?
12) Do you currently exercise, or have you done exercise in the past? Did you or do you like
to exercise? Do you have time to exercise?
13) Have you ever worked with a personal trainer? What sort of results did you get?
14) Have you ever worked with a nutritionist? How did that go?
15) Have you ever worked with your mind, subconscious programming or psychological
counseling to help you lose weight in the past? What sorts of things have you tried?
Hypnosis, EFT etc.
16) What other types of therapies have you tried to help you lose weight in the past? What
was your experience with that? Did it work? If so, why did you stop?
17) Are you taking any prescription medication? Please list the name of the medication, why
you take them and the dosages. Do you believe it’s possible to get off these medications
and are you motivated to do so?
18) Do you have any history of mental illness? If yes, this won’t affect your ability to
participate in my programs, but can we discuss it?
19) Did you have a traumatic childhood or traumatic experiences in your past?
20) Did people in your life criticize or tease your about your body?
21) What happened the last time you reached your goal weight?
22) Why is feeling better about your body important to you?
23) List three ways your life will be different when you feel good about your body.
24) List three of the challenges that you’ll face when you’re learning to feel good about your
body.
25) If you do not overcome those challenges now, what impact could that have on your life
in the future? Be specific. i.e. my marriage could suffer or even end if I don’t find my
self-worth, I’ll never get focused on living my purpose and doing what I really want to be
doing with my life if this negative thinking is holding me back….
26) Is someone or something holding you back from success? (i.e. someone in your life
currently telling you that you’re a failure or no good?)
27) Are you willing to completely commit to this program? Can you challenge yourself? Can
you leave your comfort zone behind and forget about the excuses?
28) If you’re accepted into this program will you be able to joyfully commit to investing a
significant amount of time and money to your success? Will committing to 50 hours of
work over three months be troublesome for you?
29) Do you need to consult a spouse or other individual before making a commitment to
this program? Will that be difficult?
30) Why is it important to you to be accepted into this program?
31) How much time are you able to dedicate to this program per week?
32) What is a day in your life like? Do you work long hours? Have kids? What time are you
up? When do you go to bed?
33) When will you be doing your homework? Will scheduling appointments be difficult for
you?
Please email your completed application to Ellie@EvolutionWellness.ca
If you have technical difficulties with this form, please email me for assistance.
Thanks so much, I’m looking forward to speaking with you and exploring your interest in the
program!
Ellie Steele
Certified EFT Practitioner
Registered Holistic Nutritionist
Certified Sports Nutrition Advisor
Canadian Fitness Professionals Personal Trainer Specialist
CrossFit Level One Trainer
3rd Degree Reiki Practitioner