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Getting to Know You <Confidential>
Please fill this form out as completely as possible so I can learn more about your current health and goals.
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First name
Your answer
Last name
*
Your answer
Age
*
Your answer
Email
*
Your answer
Gender
*
Female
Male
What are some of your goals over the next 8 weeks?
*
Lose weight
Gain muscle
Sleep better
Reduce stress
Achieve better work-life-family harmony
Feel happier in general
Have more energy
Understand how to eat more nutritiously
Change some of my habits
Required
Anything else you'd like to share about what you would like to get out from this program or how your Health Coach can help you?
*
Your answer
Select the biggest barriers to achieving the above goals?
Lack of time
Not sure how to achieve them
Mindset
Financial
Other:
What are 2 - 3 greatest strengths that will help you achieve these goals?
Your answer
Please select the option that BEST describes how ready you are to make changes to your lifestyle to achieve these goals.
I do not believe I need to change
I would like to change, but don't think I can
I would like to intensify changes
I recently started to make changes ( in the past 6 months)
I've made changes but relapsed
Clear selection
How important is this change to you?
*
Extremely low importance
1
2
3
4
5
6
7
8
9
10
Extremely high importance
How confident are you that you will achieve this change with the help of a coach?
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Extremely low confidence
1
2
3
4
5
6
7
8
9
10
Extremely high confidence
Medical Information
How would you describe your health?
Excellent
Very good
Good
Fair
Poor
Clear selection
Are you currently seeing a psychotherapist, psychologist or psychiatrist for mental and/or emotional issues?
Yes
No
Clear selection
Are you taking any prescription or over-the-counter medications or dietary herbs or supplements? If yes, please list the medications and state the reason for taking.
Your answer
When was the last time you visited your physician?
Your answer
Do I have permission to communicate with your physician? If yes, please state your physician’s name and contact phone number.
Your answer
Do you have or has your doctor or another licensed healthcare professional told you that you have any of the following conditions? Check all that apply.
*
Allergies. If so, please specify below.
Amenorrhea or absence of menstrual period
Anemia
Anxiety
Arthritis
Asthma
Cancer
Cardiovascular disease
Celiac disease
Chronic sinus condition
Cigarrette smoker
Crohn's disease
Depression
Diabetes
Disordered eating
Intestinal problem
Gastroesophageal reflux disease (GERD)
High blood pressure/hypertension
Hyperthyroidism
Hypothyroidism
Insomnia
Irritable bowel sydrome
Osteoporosis
Currently pregnant
Less than 3 months postpartum
Skin problem
Bipolar disorder
Other mental or learning disorders
Other:
Required
Past surgeries
Your answer
Past injuries
Your answer
Please describe any other health conditions you have, or for which you take medication.
Your answer
Has anyone in your immediate family been diagnosed with any of the following? If yes, please describe.
Heart disease
High cholesterol
High blood pressure
Cancer
Diabetes
Osteoporosis
Mental Disorders
Nutrition History
Have you ever followed at modified diet to manage a health condition? If yes, please describe.
Your answer
Do you follow a specialized diet (low-carb, gluten-free, vegan, etc). If yes, please describe the diet and reasons for following:
Your answer
Who purchases and prepares your food?
Your answer
Physical Activity History
How physically active are you each week?
Not physically active
50 - 100 mins per week
101-150 mins per week
more than 150 mins per week
Other:
Clear selection
What types of exercise do you currently engaged in? Select all that applies.
*
Cardiovascular
Strength or resistance
Flexibility
Required
Please list your favorite physical activities:
Your answer
Weight History
What would you like to do regarding your weight?
Lose
Gain
Maintain
Clear selection
What is your current weight?
Your answer
What is your height?
Your answer
What was your lowest weight in the past 5 years?
Your answer
What was your highest weight in the past 5 years?
Your answer
Other
Is there any other information that you think I should know? This information is strictly confidential and is used to help design the best program for you to achieve your health goals.
Your answer
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