Full Name *

Email *

Phone

Age

Gender

Height (example 5 ft, 7 in)

Current Weight (lbs)

GENERAL HEALTH

Please list your main health concerns & include any serious illnesses affecting your health and any medications you are taking:

Any serious hospitalizations/injuries/setbacks in the past 5 years?

At what point in your life did you feel best? What about that time (habits, emotions, activity, etc) would you like to reconnect with and incorporate into your daily well-being?

GENERAL NUTRITION

How would you rate your nutrition?

I have a well balanced diet and eat mostly whole foods.

My diet is fairly well balanced and I eat a good amount of whole foods & a few packaged/convenience foods.

I'm not sure if my diet is well balanced. I also tend to eat an equal amount of whole foods & packaged/convenience foods.

I eat more packaged/convenience foods than whole foods.

I eat only packaged/convenience foods.

None of these examples describe my nutrition choices.

If you chose "Other" type it below

What percentage of your food is home-cooked?

Are you interested in cooking at home more?

Yes

PHYSICAL ACTIVITY

How often do you exercise per week currently?

What types of exercise do you do on a regular basis?

Have you had any injuries or surgery that require specialized training and rehabilitation?

Aside from injuries or surgery, do you experience any additional restrictions to your mobility? If so please describe in detail and include any treatment you are currently receiving.

What’s one activity you want to be able to do in one month’s time?

What’s one activity you want to be able to do in six month’s time?

PATH TO SUCCESS

What do you feel good about in your life right now?

What is your vision for yourself? and How do you see yourself in a year and how would you like to feel?

What changes would you like to make in order to achieve your vision?

How would you describe your health journey up to this point?

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

Yes

Are you interested in a short term or a long term transformation?

Short Term Goal

Long Term Transformation

If you chose the "Long term transformation," describe your long-term goals in detail including the positive outcomes you desire as a result of health coaching? (Some examples include: weight loss, diminished cravings, better sleep, more energy, reduced pain and inflammation, enhanced mood, reduced brain fog, improved athletic performance, etc.)

What do you hope for in a coaching relationship? and Where do you feel you need the most support and accountability?

What is motivating you to pursue health coaching? What is your WHY? This is a very important step so please dig deep on this one because your overall success will depend on it.

Does this motivation differ from what you have felt in the past attempts to change your health?

Do you perceive any barriers to your desires to make any changes?

How much ready are you to make these changes?

I'm Ready

Somewhat Ready

Not Ready

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