Coaching Intake Form - Cryo Recovery and Wellness

Wellness Coaching
Intake Form

Are you a new wellness coaching customer? Then fill out the form below to submit your information and get started.

Step 1 of 10

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Personal Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Age(Required)

Gender(Required)

Main Health Goals

Please describe your top 3 health and lifestyle transformations you hope to achieve during this Health Coaching realtionship.(Required)

Describe the patterns you seem to fall into again and again with regards to making health and lifestyle trasformation. What other diets, programs, or approaches have you tried in the past, and what were your results?(Required)

Describe your beliefs about your ability to transform your own health.(Required)

What support do you have at home, at work, and in your life to succeed in this program?(Required)

What barriers can you perceive or predict? What aspects of your home, work, and live have previously detracted from your ability to succeed?(Required)

What hobbies, interests, and passions do you partake in?(Required)

Please share any information you feel is pertinent with regards to your level of commitment through this process. What is going to motivate you to keep going even when it gets a little uncomfortable?(Required)

Nutrition

Diet snapshot. Generally, how would you describe your current diet? Provide a basic snapshot of what an average day looks like: Breakfast, lunch, dinner, snacks, treat and beverages. Please include times of day as well.(Required)

Protein. Which protein sources do you eat? How often do you eat them?(Required)

Refined carbohydrates. What types of refined carbohydrate snacks (like candies, crackers, cookies, pastries, baked goods) do you eat? How often do you eat them?(Required)

Whole grains. What types of whole grains do you eat? How often do you consume them?(Required)

What are your favorite foods?(Required)

Do you try to avoid any certain types of foods?(Required)

What foods do you crave? How often do you give in to the cravings?(Required)

Do you experience any symptoms/feelings/behaviors if meals are missed? Explain.(Required)

Are you currently taking any nutritional supplements? List all.(Required)

Beverages

How many glasses or servings of the following do you have in a day, week, or month? Please provide quantity and frequency.

Quantity

Frequency

Quantity

Frequency

How do you take your coffee?

Quantity

Frequency

How do you take your tea?

Quantity

Frequency

Please provide details around your consumption of juices: type, when, why?

Quantity

Frequency

Quantity

Frequency

Please provide details around your dairy and non-dairy milk usage: type, when, why?

Quantity

Frequency

Please provide details: smoothie/shake ingredients; when and why you consume smoothies or shakes, etc.

Quantity

Frequency

Quantity

Frequency

Quantity

Frequency

Please provide details: What type of alcoholic drink, when, why?

Energy and Mood

Describe your energy levels throughout the day. Do you have highs and lows? When?(Required)

On a scale of 1 to 10, how would you rate your stress level?(Required)

Describe your sources of stress.(Required)

How do you react to stress? Do you rely on any coping mechanisms?(Required)

Sleep

Sleep Quality: How well do you sleep? (Check all that apply)(Required)

I fall asleep easily.

I stay asleep well.

I wake up feeling rested.

I snore.

I have sleep apnea.

I have trouble falling asleep.

My Mind wanders which keeps me awake.

I wake up in the night but can get back to sleep usually.

I wake in the night and then can't get back to sleep.

I struggle to wake up when my alarm goes off.

I feel unrested when I wake up.

Sleep Quantity: How many hours of sleep do you get most nights?(Required)

Please enter a number from 0 to 24.

What time do you typically go to bed?(Required)

Hours

Minutes

AM/PM

What time do you typically wake up?(Required)

Hours

Minutes

AM/PM

What else should your coach know about your sleep habits, patterns, quantity, and quality?(Required)

Exercise & Movement

Non-exercise movement. Non-exercise movement can include things like the walking you do throughout your day, moving around, chores, manual/physical tasks, fidgeting, etc. Please describe your daily non- exercise movement(Required)

Exercise. Exercise is described as the deliberate attempts you make to move your body; your workouts, weight lifting sessions, yoga or fitness classes, and taking long walks. What do you do for exercise? Describe the types of activities, frequency, duration, intensity, etc.(Required)

Are you a competitive athlete?(Required)

Yes

Please describe your sport.(Required)

What are your fitness goals? Check all that apply:(Required)

General health

Muscle mass gain

Fat loss

“Looking Good Naked"

Improved physical performance

Describe your performance goals

Improved bone density

Improved cardiorespiratory health

Preventing age-related muscle loss

Stress management

Improved mood

Other

Please describe your other fitness goal:(Required)

Do you have any physical limitations in terms of your ability to partake in an exercise program?(Required)

Bowel Health

How often do you have a bowel movement?(Required)

Do you ever have difficult or unusual bowel movements?(Required)

Please describe what difficulties or what is unusual.(Required)

Work and Life

What do you do for work?(Required)

Do you usually enjoy your work?(Required)

How many hours a day do you work?(Required)

What type of schedule do you work?(Required)

Briefly explain your random schedule:(Required)

What is your family and home-life situation? Married? Children? Taking care of elderly parents? Please describe with as much detail as you feel comfortable sharing.(Required)

Medical History

Current health conditions. Have you been diagnosed with any diseases, and/or are you on any prescribed medications?(Required)

Have you ever been hospitalized, had any major surgery? Please describe.(Required)

Do you have any allergies or sensitivities?(Required)

Yes

Please describe your allergies or sensitivities:(Required)

Do you smoke or vape?(Required)

Yes

How many cigarettes per day (or equivalent if you vape)?(Required)

Do you partake in recreational drugs?(Required)

Yes

Please describe which ones, how often and why:(Required)

Describe any pertinent family medical history.(Required)

Are you or could you be pregnant?(Required)

Are you pre-menopausal, peri-menopausal, menopausal or experiencing menopause symptoms?(Required)

Please describe:(Required)

Additional Information

Do you have any additional notes, comments or questions?

Acknowledgement

Acknowledgement(Required)

I understand that the services provided are at all times restricted to consultation on the subject of health matters intended for general wellbeing and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being acknowledged voluntarily.(Required)

Signature(Required)

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Wellness Coaching
Intake Form

Personal Information

Main Health Goals

Nutrition

Beverages

Energy and Mood

Sleep

Exercise & Movement

Bowel Health

Work and Life

Medical History

Additional Information

Acknowledgement

Office Info

Business Hours

New Guests

Company

Services

Wellness Coaching Intake Form

Personal Information

Main Health Goals

Nutrition

Beverages

Energy and Mood

Sleep

Exercise & Movement

Bowel Health

Work and Life

Medical History

Additional Information

Acknowledgement

Office Info

Business Hours

New Guests

Company

Services

Wellness Coaching
Intake Form