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Initial Health Coaching Assessment Questionnaire
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* Indicates required question
Email
*
Your email
Full Name
*
Your answer
Please schedule your program kickoff call.
Visit my calendar link here
and schedule your program kickoff call
(*required)
What date did you select for your kickoff call in the link above?
*
MM
/
DD
/
YYYY
How specifically would you like your habits, your health, your eating and or your body to be different?
*
Your answer
Out of all the changes you'd like to make, which ones feel most important/urgent and why?
*
Your answer
Have you tried anything in the past (or recently) to change your habits, your health, your eating...?
*
Your answer
Which of those worked well for you and why?
*
Your answer
Which of those didn't work well for you and why not?
*
Your answer
If you were to consider making more changes to your habits, your health, your eating, and/or your body, what might those be?
*
Your answer
Until now, what has blocked you or held you back from changing these things?
*
Your answer
How would you rank your overall nutritional habits right now?
*
horrible
1
2
3
4
5
6
7
8
9
10
excellent
Approximately how many hours a week do you participate in physical activity(housework, gardening, walking, moving around at work).
*
Fewer than 5 hours
5-9 hours
10-14 hours
15-19 hours
20 or more
Required
Are you regularly active in sports and/or exercise.
*
fewer than 5 hours
5-9 hours
10-14 hours
more than 14 hours.
Required
What type of other movement or activities do you do?
*
Your answer
Who lives with you?
*
Your answer
Do you have children or other dependents? If so, how many and what are their ages?
*
Your answer
Who does most of the grocery shopping in your household?
*
Your answer
Right now, how much do the people and things around you support your health, fitness, and/or behavior change?
*
Not at all
1
2
3
4
5
6
7
8
9
10
Completely
Have you been diagnosed( currently or in the past ) with any significant medical conditions or injuries?
*
yes
no
Right now, do you have any specific health concerns, such as illness, pain or injury?
*
Your answer
Right now are you taking and medications either over the counter or prescription?
*
Yes
No
On a scale of 1-10 how would you rank your health right now.
*
Not good
1
2
3
4
5
6
7
8
9
10
Awesome!
Why did you choose the number above?
*
Your answer
On an average week how many hours do you spend...1. in paid employment 2.Taking care of others 3.At school or doing work 4.Volunteering 5.Housework/errands 6.Travelling or commuting?
*
Your answer
Adding up all of the above how many hours do you spend doing all these activities?
*
Your answer
On a scale of 1-10 how do you feel about your schedule, time use, and overall business?
*
My life is panicked and insane.
1
2
3
4
5
6
7
8
9
10
My life is perfectly calm and relaxed.
Think about all the activities you're involved in and assess the following as best you can...
What is your typical stress level on any given day?
*
no stress
1
2
3
4
5
6
7
8
9
10
extreme stress
On average how many solid hours of sleep do you get a night?
*
4 or fewer
5
6
7
8 or more
How do you normally cope with your stress?
*
Your answer
How READY are you to change your behaviors and habits?
*
Not at all
1
2
3
4
5
6
7
8
9
10
Completely
How WILLING are you to change your behaviors and habits?
*
Not at all
1
2
3
4
5
Completely
How ABLE are you to change your behaviors and habits?
*
Not at all
1
2
3
4
5
6
7
8
9
10
Completely
Coaching Agreement
*
Please review the Coaching Agreement document linked here
before checking the box below.
By checking this box, you hereby understand and agree to all the terms and conditions of the Coaching Agreement linked above.
Required
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