First Name
Last Name
Email
Phone
Age
Under 18
18-24
25-34
35-44
45-54
55-64
65 or Above
Prefer Not to Answer
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)
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)
How many glasses or servings of the following do you have in a day, week, or month? Please provide quantity and frequency.
Quantity
Quantity
How do you take your coffee?
Quantity
Quantity
Please provide details around your dairy and non-dairy milk usage: type, when, why?
Quantity
Please provide details: smoothie/shake ingredients; when and why you consume smoothies or shakes, etc.
Quantity
Quantity
Quantity
Please provide details: What type of alcoholic drink, when, why?
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)
1 - No Stress
2
3
4
5 - Moderate Stress
6
7
8
9
10 - Extremely High Stress
Describe your sources of stress.(Required)
How do you react to stress? Do you rely on any coping mechanisms?(Required)
Sleep Quality: How well do you sleep? (Check all that apply)(Required)
I fall asleep easily.
My Mind wanders which keeps me awake.
I struggle to wake up when my alarm goes off.
I stay asleep well.
I have sleep apnea.
I wake up in the night but can get back to sleep usually.
I feel unrested when I wake up.
I wake up feeling rested.
I have trouble falling asleep.
I wake in the night and then can't get back to sleep.
Sleep Quantity: How many hours of sleep do you get most nights?(Required)
What time do you typically go to bed?(Required)
What else should your coach know about your sleep habits, patterns, quantity, and quality?(Required)
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)
Please describe your sport.(Required)
What are your fitness goals? Check all that apply:(Required)
General health
Fat loss
Improved physical performance
Improved bone density
Preventing age-related muscle loss
Improved mood
Muscle mass gain
“Looking Good Naked"
Describe your performance goals
Improved cardiorespiratory health
Stress management
Other
Do you have any physical limitations in terms of your ability to partake in an exercise program?(Required)
How often do you have a bowel movement?(Required)
Once A Day
Twice A Day
Three Times a Day
Four Or More Times A Day
Every Other Day
Do you ever have difficult or unusual bowel movements?(Required)
Please describe what difficulties or what is unusual.(Required)
What do you do for work?(Required)
Do you usually enjoy your work?(Required)
Always
Often
Sometimes
Not Very Often
Not At All
How many hours a day do you work?(Required)
What type of schedule do you work?(Required)
Regular Schedule
Random Schedule
Shift Work
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)
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? If YES, Please describe your allergies or sensitivities:
Do you smoke or vape? If YES, How many cigarettes per day (or equivalent if you vape)?
Do you partake in recreational drugs? If YES, Please describe which ones, how often and why:
Describe any pertinent family medical history.
Are you pre-menopausal, peri-menopausal, menopausal or experiencing menopause symptoms?(Required)
Do you have any additional notes, comments or questions?
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