Please answer the following questions to the best of your ability.

There are no right or wrong answers. The information you provide will be treated in a confidential manner and will be a part of the overall evaluation process.

Thank You

Name *

First

Last

Tell me more about yourself.

By learning more about your lifestyle and your habits, I can take better care of you and make sure coaching is a good fit for your goals and individual needs.

Age *

Gender *

Male
Female

Email *

Phone *

Preferred Method of Contact *

Email
Call
Text
Other

Emergency Contact & Phone #

What Do You Want?

Lose Weight/Fat
Gain Weight
Maintain Weight
Add Muscle
Improve Physical Fitness
Look Better
Feel Better
Have More Energy and Vitality
Get Control of Eating Habits
Get Stronger
Physique Competition/Modeling
Improve Athletic Performance

In general, what are your goals? Choose as many as you like

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?

What do you expect from me as your coach?

What are your prepared to do to work towards your goals?

What do you want to change?

Have you tried anything in the past to change your habits, your health, your eating, and/or your body?

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?

List your 10 favorite Whole Foods

How, specifically, would you like your habits, your health, your eating, and/or your body to be different?

Have you already made changes to your habits, your health, your eating, and/or your body recently?

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?

Right now, how would you rank your overall eating/nutrition habits?

Why?

Is there a specific body part that you would like to develop?

Are you regularly active in sports and/or exercise? Are you regularly active in sports and/or exercise?

If so, approximately how many hours per week? If so, approximately how many hours per week?

Fewer Than 5 Hours
5-9 Hours
10-14 Hours
15-19 Hours
20 or More Hours

What other types of movement and/or activities do you do?

What's around you?

Who lives with you? Who lives with you?

Spouse or Partner(s)
Roomate(s)
Children
Pet(s)
Other Family Members

Check all that apply.

Do you have children?

If yes, how many and what are their ages?

Who does most of the grocery shopping in your household? Who does most of the grocery shopping in your household?

Me
Spouse or Partner(s)
Roomate(s)
Child(ren)
Other Family

Who does most of the cooking in your household?

Me
Spouse or Partner(s)
Roomate(s)
Child(ren)
Other Family

Who decides on most of the menus/meal types in your household? Who decides on most of the menus/meal types in your household?

Me
Spouse or Partner(s)
Roomate(s)
Child(ren)
Other Family

Right now, how much do the people and things around you support health, fitness, and/or behavior change?

What's your health like?

Have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries?

Right now, do you have any specific health concerns, such as illnesses, pain, and/or injuries?

Right now, are you taking any medications, either over-the-counter or prescription?

On a scale of 1-10, how would you rank your health right now?

Why?

How are you spending your time?

In an average week, how many hours do you spend...

Adding up all of these things, how many total hours per week do you spend doing all these activities?

On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?

How is your stress and recovery?

Think about all of the activities that you're involved in (e.g. work, school, caregiving, housework, travel). Then assess as best you can.

Given all the demands of your life, what is your typical stress level on an average day? Given all the demands of your life, what is your typical stress level on an average day?

On average, how many hours per night do you sleep? On average, how many hours per night do you sleep?

4 or Fewer Hours
5 Hours
6 Hours
7 Hours
8 Hours
9 Hours
10 or More Hours

How do you normally cope with stress?

How ready, willing, and able are you to change?

Right now, on a scale of 1-10.

How READY are you to change your behaviors and habits?

How WILLING are you to change your behaviors and habits? (copy)

How ABLE are you to change your behaviors and habits?

DISCLAIMER * 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. *

YES, I do accept full resposibility for my decision
NO, I do NOT accept full resposibility for my decision

Name *

First

Last

Email *

Phone *

Comment or Message

Website

Please answer the following questions to the best of your ability.

There are no right or wrong answers. The information you provide will be treated in a confidential manner and will be a part of the overall evaluation process.

Thank You

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