Holistic Health Coaching Questionnaire

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First and Last Name *

Email Address *

Do you have goals you are looking to achieve? Or do you need a change but have no idea where to start? please list your goals or lack of below. *

Please prioritize the above list from most important to less important. *

What are you interest, hobbies, likes? Please include the ones (if any) that you have let fall by the wayside. *

How do you sleep? *

Um, what's sleep

I'm a light sleeper, any little noise wakes me up

I can get to sleep pretty easy but wake up a couple times throughout the night

It takes me forever to fall asleep, even though I'm exhausted.

I wake up tired

I sleep like a rock

I wake up feeling great

Required

Give a brief description of breakfast, lunch and dinner. Please answer even if you are not looking for weight loss. *

Do you have a daily routine (wake up and go to sleep the same time everyday, meals at the same time...) *

Yes

Required

In the last month, how often have you been upset because of something that happened unexpectedly? *

Sometimes

All the time

Required

In the last month, how often have you felt nervous and “stressed”? *

Not really

Sometimes

Everyday

In the last month, how often have you felt confident about your ability to handle your personal problems? *

Not very

kind of

Absolutely

In the last month, how often have you felt difficulties were piling up so high that you could not overcome them? *

Not really

A little

Everyday

Are you looking to change a specific behavior? *

Yes

Required

Are you willing to make this behavioral change a top priority? *

Yes

Not Sure

Have you tried to change this behavior before? *

Yes

Are you committed to making this change, even though it may prove challenging? *

Yes

Do you have support for making this change from friends, family, and loved ones? *

Yes

Besides health reasons, do you have other reasons for wanting to change this behavior? *

Yes

Required

Are you prepared to be patient with yourself if you encounter obstacles, barriers, and/or setbacks? *

Yes

Check all that apply *

My energy fluctuates and often comes in bursts

My appetite is variable

My skin is frequently dry.

I prefer warm/hot weather over cold/dry weather.

I'm a light sleeper and have difficulty falling asleep.

I'm creative and imaginative.

My mind is active and restless.

I learn quickly, but forget just as quick.

I have a tendency to feel anxious, nervous, and insecure.

I don't really have a regular/daily routine.

Required

Check all the apply *

My appetite is strong.

I sweat easily.

I prefer cooler weather and become irritable in hot weather.

I am goal oriented and achieve anything I put my mind to.

I am a perfectionist.

I tend to become irritable, impatient and/or angry.

I am critical of myself.

I enjoy competition.

I become irritable if I skip/miss a meal.

Required

Check all the apply *

I have abundant strength and stamina. (but I may not use it that much)

I sleep deeply and soundly.

I catch colds frequently.

I have a big heart and prefer to focus on the good in the world.

I prefer a slow and relaxed lifestyle.

My long-term memory is great.

I'm methodical in my actions.

I let negative emotions build up rather than addressing them.

I usually let others lead.

I am a natural listener and frequently help others with their problems.

Required

Anything you would like to add or let me know before we begin our sessions?

If you have not booked your first session yet, please do so by visiting https://www.holistichealthcoachingwny.com/sessions so we can get started.

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