JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Pre Assessment Questionnaire
Thank you for considering the S.E.X (Sleep.Eat.eXercise) Program! This self-assessment questionnaire will help us to get to know you better. There are no right or wrong answers, simply answer as accurately as possible, for your unique situation. Once completed, we will contact you via WhatsApp to arrange your complimentary discovery session.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Tell me more about yourself.
By learning more about your lifestyle and your habits, we can take better care of you and make sure coaching is a good fit for your goals and individual needs.
1. What do you want? In general, what are your goals? Check all that apply.
Lose weight/fat
Gain weight
Maintain weight
Add muscle
Improve physical fitness
Manage chronic diseases e.g. diabetes, cardiovascular, cancer, joint pains, depression, etc
Quit smoking
Manage stress
Have more energy and vitality
Get control of eating habits
Sleep better
Improve overall health
2. Please list your top concerns about your health, eating habits, fitness, and/or body.
Your answer
2. 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? If so, what?
Your answer
Which of those things didn't work well for you?
Your answer
3. Until now, what has blocked you or held you back from reaching your health goals?
No time.
Not my priority before.
No idea how to get started.
Other:
4. Right now, how would you rank your overall eating/nutrition habits?
Horrible
1
2
3
4
5
6
7
8
9
10
Awesome!!!
Clear selection
5. Are you regularly active in sports and/ or exercise? If so, approximately how many hours per week?
Fewer than 5 hours
5-9
10-14
15-19
20 or more
Clear selection
What types of sports and/or exercise do you typically do?
Your answer
6. Who does most of the grocery shopping in your household? Check all that apply.
Me
Spouse or partner(s)
Roommate(s)
Child(ren)
Other family
7. Who decides on most of the menus / meal types in your household? Check all that apply.
Me
Spouse or partner(s)
Roommate(s)
Child(ren)
Other family
8. Right now, how much do the people and things around you support health, fitness, and/or behavior change?
Not at all
1
2
3
4
5
6
7
8
9
10
Completely
Clear selection
9. What's your health like? Tick the boxes that apply to you.
I have been diagnosed (currently or in the past) with a significant medical condition(s) and/or injuries.
Right now, I have one or more chronic conditions, such as cardiovascular problems, diabetes, cancer, joint pains, etc.
I am currently taking medication, either over-the-counter or prescription.
I have already gone for treatment and am now in recovery.
I have no medical condition.
Other:
What chronic conditions do you have, if any?
Your answer
10. On a scale of 1-10, how would you rank your health right now?
WORST
1
2
3
4
5
6
7
8
9
10
AWESOME!!!
Clear selection
11. On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?
MY LIFE IS PANICKED AND INSANE
1
2
3
4
5
6
7
8
9
10
MY LIFE IS PERFECTLY CALM AND RELAXED
Clear selection
12. 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
Clear selection
13. How ready, willing, and able are you to change to achieve your health goals?
Right now, on a scale of 1-10:
How READY are you to change your behaviors and habits?
NOT AT ALL
1
2
3
4
5
6
7
8
9
10
COMPLETELY
Clear selection
How WILLING are you to change your behaviors and habits?
NOT AT ALL
1
2
3
4
5
6
7
8
9
10
COMPLETELY
Clear selection
How ABLE are you to change your behaviors and habits?
NOT AT ALL
1
2
3
4
5
6
7
8
9
10
COMPLETELY
Clear selection
Preferred Name:
*
Your answer
Gender:
Female
Male
Clear selection
Date of Birth:
*
MM
/
DD
/
YYYY
Please contact me to arrange a suitable time and date for my complimentary online first health coaching session. My WhatsApp Contact No:
*
Your answer
How did you find out about us?
*
Health Talk
Facebook
Friend
Magazine article
Others
If it's a Friend or Others, please specify who or what:
*
Your answer
I prefer a health coach who is:
*
Male
Female
No preference
Gender
Male
Female
No preference
Gender
I prefer a health coach who speaks:
*
Chinese
English
Malay
Language
Chinese
English
Malay
Language
Please recognize that it is your responsibility to work directly with your health care provider before, during and after seeking nutrition and/or health coaching with Health Coach International. 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 responsibility for your decision.
*
I agree
I disagree
* All responses will be treated in strict confidence, and will not be divulged to any third party except when analysed as a group without reference to any individual.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Health Coach International.
Report Abuse
Forms
