Health Assessment Form: Let's Unearth Your Health & Lifestyle Concerns
Please take 5 minutes to complete this form.
It will help both of us get a little clearer on your current concerns and desired goals.
This way I will be able to steer the conversation in a helpful direction so that you can get the maximum benefit of our time together.
Please be as honest and direct with your answers.
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Email *
Name & Surname *
Mobile number (for conversation via what's app) *
Let's start by finding out where you are at. Check all that apply. Be honest with yourself: *
Required
I want... Please check all that apply: *
Required
How would you rate your overall energy? *
How would you rate your overall sleep patterns? *
Paint the picture for me, where are you now and what is your biggest concern/challenge? *
In one word, what is the main thing you are looking for help with? *
On a scale of 1-5, what is your level of stress at this time? *1. Being none 5. Being unbearable *
None
Unbearable
What is your biggest source of stress or overwhelm at this time?
How IMPORTANT is change to you right now? * 1. I can wait  - 5. It's my main priority *
I can wait
It's my main priority
How CONFIDENT are you about making these changes? * 1. Not confident - 5. Confident *
Not Confident
Confident
Are you willing to prioritize the time it takes for your growth process? Please describe what that looks like in action. *
If we were to be having this conversation in 12 months time, how would you know your work & effort had been successful? What does an ideal outcome look like? *
What 3 things are keeping you from your best self? *
Required
Have you worked with a coach before? *
If yes, please describe what the coach and the program was like. *
Are you ready to invest in your growth process financially? *
Required
Would you prefer to chat via Zoom or Whatsapp? *
Any additional information you would like to share?
Thank you for taking the time to answer these questions. I know it was a lot! But I hope it has given you some clarity :-)

If you would like to have a free 20 minute chat with me about your answers and to find a way to move forward, click here to get on my calendar if you haven't done so yet. 

Please note that I am not into pushy sales or anything like that AT ALL. Our time together gives me a chance to assess where you are in your life, what challenges you are facing and if you possibly qualify for or are the right fit for one of my courses. 

I will be giving you honest and open feedback at the end. And will support you in which ever way I know best for you so that you can start taking steps in the right direction. 

Sending love
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Nina
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