Name
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First Name
Last Name
Date
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MM
DD
YYYY
Gender
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Date of Birth
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MM
DD
YYYY
Email
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Phone
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(###)
###
####
How do you prefer to be contacted?
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Email
Video Call
Text
In general, what are your goals? (Check all that apply)
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Please list all concerns you have about your eating habits, health, fitness, and/or body.
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Of all the concerns above, which feel the most important to you?
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What are some things you expect from your coach?
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Have you tried anything in the past to improve your eating habits, health, fitness and/or body?(if so, what?)
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Which of those things worked well for you?
Which of those things did not work well for you?
How, specifically, would you like your eating habits, health, fitness, and/or body to be different?
Until now, what has blocked you from making changes?
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Right now, how would you rank your fitness level?
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10-Awesome!
9
8
7
6
5-Average
4
3
2
1-Horrible!
Approximately how many hours per week do you spend doing exercise/sports?
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What type of sports/exercise do you typically do?
Approximately how many hours a week do you perform other forms of activity?(housework, walking dog, gardening)
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What types of activities do you do?
Right now, how much do the people and things around you support health, fitness, and behaviour change?
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10-Completely supportive
9
8
7
6
5-Somewhat supportive
4
3
2
1-Not at all
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries?
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Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries?
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Right now, are you taking any medications, either over-the-counter or prescription?
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On a scale of 1-10, how would you rank your health right now?
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10-Amazing
9
8
7
6
5-Average
4
3
2
1-Horrible
Why?
In a typical week, where do you spend your time?(check all that apply)
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Approximately how many hours total are spent on these in a week?
On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?
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10-My life is calm and relaxed
9
8
7
6
5-I somehow manage all the stress
4
3
2
1-My schedule is packed and chaotic
Given all the demands of your life, what is your typical stress level on an average day?
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10-Extreme Stress
9
8
7
6
5-Average
4
3
2
1-No Stress
On average, how many hours per night do you sleep?
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How do you normally cope with your stress?
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How READY are you to change your behaviors and habits?
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10-Completely
9
8
7
6
5-Maybe
4
3
2
1-Not at all
How WILLING are you to change your behaviors and habits?
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10-Completely
9
8
7
6
5-Maybe
4
3
2
1-Not at all
How ABLE are you to change your behaviors and habits?
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10-Completely
9
8
7
6
5-Maybe
4
3
2
1-Not at all
Disclaimer
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Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking
nutrition and / or fitness consultation.
Any information provided is not to be followed without prior approval of your doctor.
If you choose to use this information without
such approval, you agree to accept full responsibility for your decision.
First Name
Last Name
