Survey – Welcome Part 2-Your Medical History (Anonymous) As a reminder, the following section survey contains optional questions about your medical history. This portion is anonymous. Both your Coach and Whole30 HQ will only see the data in a group, not by individual survey results. We hope you will take time to complete this survey, because the data is extremely useful to us in better understanding how clients like you are experiencing the Whole30, which will help Whole30 develop more effective education.Coach NameYour Medical HistoryAs your Coach, it’s good for me to be aware of any medical history that might impact - or be impacted by - your Whole30 experience. It also helps me (and you) assess how these things might have changed at the end of your Whole30.In the past 5 years, have you had abnormal lab values in any of the following areas? (Check all that apply)(Required) HgA1C (blood sugar) Fasting glucose LDL Cholesterol Blood pressure Triglycerides C-reactive protein (CRP) Thyroid (TSH, T3/T4, TPO-Ab, Tg-Ab) Which of the following symptoms have you experienced over the last 30 days?(Required)DailyAlmost dailySometimesRarelyNeverI don’t knowAcid reflux, heartburn, or indigestionAllergies or sinus issuesAnxiety or depressionBack painBloatingBrain fogConstipationCravingsFatigue or low energyFrequent illnessGI issues (like constipation, diarrhea, gas)Headaches or migrainesJoint pain (general or arthritis)Mood swingsSkin issues (like acne, eczema, or psoriasis)Sleep issues (like frequent waking, insomnia, or oversleeping)StomachachesHow frequently do you take over-the-counter medications to treat discomfort from conditions like headaches, pain, reflux, or allergies? Daily Weekly Monthly Never Have you experienced a significant weight change (more than 10% of your body weight) in the past year? Yes No If you answered “yes” to the question above, what do you attribute the weight change to? Your Emotional HealthI realize the questions in this section can be sensitive. This information will only be used to help me, you, and Whole30 HQ better understand how Whole30 impacts changes in your body awareness, body acceptance, self-efficacy, and confidence. It can also help me to better tailor your Coaching experience. Please indicate whether each of the following questions is true about you never, seldom, sometimes, often, or always.(Required)Never (1)Seldom (2)Sometimes (3)Often (4)Always (5)I respect my body.I feel good about my body.I feel that my body has at least some good qualities.I take a positive attitude toward my body.I am attentive to my body’s needs.I feel love for my body.I appreciate the different and unique characteristics of my body.My behavior reveals my positive attitude toward my body; for example, I hold my head high and smile.I am comfortable in my body.I feel like I am beautiful even ifI am different from media images of attractive people (e.g., models, actresses/actors).Please indicate whether you strongly disagree, disagree, neither agree or disagree, agree, or strongly agree.Strongly disagree (1)Disagree (2)Neither agree nor disagree (3)Agree (4)Strongly agree (5)I will be able to achieve most of the goals that I set for myself.When facing difficult tasks, I am certain that I will accomplish them.In general, I think that I can obtain outcomes that are important to me.I believe I can succeed at most any endeavor to which I set my mind.I will be able to successfully overcome many challenges.I am confident that I can perform effectively on many different tasks.Compared to other people, I can do most tasks very well.Even when things are tough, I can perform quite well.Optional Demographic InformationIf you feel comfortable, please provide the following demographic information. This question is optional and will be used to help me (and Whole30 HQ) better understand how people in different age groups experience Whole30.What is your age bracket?(Required) 20 years old or younger 21-30 30-39 40-49 50-59 60-69 70-79 80-89 90 or older Thank you for taking time to share this information with us.
