Name *
Name
Date of Birth
Email Address
Phone
Phone
Please list all of your concerns about your health, eating habits, fitness, and/or body.
Out of all of the above concerns, which ones feel most important/urgent?
Why?
What do you expect from me as your coach?
What are you prepared to do to work towards your goals?
If so, what?
Which of those things worked well for you? (Even if you might not be doing it right now/)
Which of those things didn’t work well for you?
How, specifically, would you like your habits, your health, your eating, and/or your body to be different?
If so, what?
If you were to consider making further 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?
Why?
What types or sports and/or exercise do you typically do?
What other types of movement and/or activities do you do?
If yes, how many and what are their ages?
The people and things aroundyou support health, fitness, and/or behavior change.
The people and things aroundyou support health, fitness, and/or behavior change.
Why?
In an average week, how many hours do you spend in paid employment?
In an average week, how many hours do you spend at school or doing school work?In
In an average week, how may hours do you spend traveling and/or commuting?
In an average week, how many hours do you spend taking care of others? (e.g. children, person with a disability, older person)
In an average week, how many hours do you spend doing other unpaid work? (e.g. housework, errands)
In an average week, how many hours do you spend volunteering?
Adding up all these things, how many total hours per week do you spend doing all these activities?
How do your normally cope with your stress?
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.
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