First Last Name and Date
Email
*
Tell me more about yourself. By learning more about your lifestyle and your habits, I can take better care of you and make sure coaching is a good fit for your goals and individual needs.
Phone
(###)
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How do you prefer for me to contact you?
Emergency contact name and phone number
In general, what are your goals? Check all that apply.
If not listed above, what other health goals are you interested in achieveing?
How, specifically, would you like your habits, your health, your eating, and / or your body to be different?
Out of all of the changes you’d like to make, which ones feel most important / urgent?
Have you tried anything in the past (or recently) to change your habits, your health, your eating, and / or your body? If so, what?
If so what have you tried?
Which of those things worked well for you, and why? (Even just a little bit, and even if you might not be doing them right now.)
Which of those things didn’t work well for you, and why not?
If you were to consider maybe making more changes to your habits, your health, your eating, and / or your body, what might those be?
Until now, what has blocked you or held you back from changing these things?
Right now, how would you rank your overall eating / nutrition habits?
1 = Horrible / 10=Awesome!
Why?
Are you regularly active in sports and / or exercise? Y N
If so, approximately how many hours per week?
What types of sports and / or exercise do you typically do?
Approximately how many hours a week do you do other types of physical activity? (e.g., housework, walking to work or school, home repairs, moving around at work, gardening)
What other types of movement and / or activities do you do?
CheckWho lives with you? Check all that apply.box
If you have children, how many and what are their ages? (leave blank if no children)
Who does most of the grocery shopping in your household? Check all that apply.
Who does most of the grocery shopping in your household? Check all that apply.
Who does most of the cooking in your household? Check all that apply.
Who decides on most of the menus / meal types in your household? Check all that apply.
Right now, how much do the people and things around you support health, fitness, and / or behavior change?
1 = Not at all / 10 = Completely!
Have you have been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries?
Right now, are you taking any medications, either over-the-counter or prescription?
Right now, are you taking any medications, either over-the-counter or prescription?
On a scale of 1-10, how would you rank your health right now?
1 = Worst / 10 = Awesome!
Why
In paid employment
Taking care of others? (e.g., children, person with a disability, older person)
At school or doing school work?
Doing other unpaid work? (e.g., housework, errands)
Traveling and / or commuting?
Volunteering?
Adding up all these things, how many total hours per week do you spend doing all these activities?
On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?
1 = My life is panicked and insane / 10 = My life is perfectly calm and relaxed
Think about all the activities you’re involved in (e.g., work, school, caregiving, housework, travel). Then assess as best you can: Given all the demands of your life, what is your typical stress level on an average day?
1 = No stress / 10 = Extreme stress
On average, how many hours per night do you sleep?
How do you normally cope with your stress?
How READY are you to change your behaviors and habits?
1 = Not at all / 10 = Completely
How WILLING are you to change your behaviors and habits?
How ABLE are you to change your behaviors and habits?
1 = Not at all / 10 = Completely
AreaWhat do you expect from me as your coach?
What are you prepared to do to work towards your goals?
Client acknowledgment (Please type your name)