Comprehensive Personal Health & Wellbeing Assessment
Hello there.  Fill this out the best you can.  We will speak in more detail later.  I look forward to helping you acocmplish your health goals.
Chris Belin, Certified Health Coach
 716-207-0134  chris@chrisbelin.com
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Today's Date *
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How did you hear about me? *
Name and Phone/Email *
Age? *
Height and weight? (Answer this if  you feel comfortable.
What is your health goal(s)? *
Required
Why is that your goal(s)? *
How will you feel/look when you get there?
What else have you tried?
On a scale of 1-10, how committed are you to these goals?
Not at all committed..
I will do whatever it takes!
Clear selection
How do you feel on a daily basis now? *
Select those that are true for you.
What obstacles do you foresee?  Time?  Money?  Motivation? *
Do you have support?  An accountability partner or two? *
What motivates or inspires you?  Do you require external motivation to keep going?  Do you give up easily when stressed? *
Do you have any dietary restrictions, intolerances, allergies? *
What are eating now for breakfast? *
How many times a week are you "eating out"? *
Do you drink coffee? How do you take it? *
Do you drink alcohol?  How often? *
Are you "regular"? *
Are you on any medications? *
How many times a week do you move your body? *
Do you drink enough water? *
How many hours of sleep are you getting? *
On a scale from 1-5, how bad is your stress?
Low and managed
I want to scream almost daily
Clear selection
How often do you want to hear from me?
Clear selection
What technology are you familiar with and comfortable using?
Do I have your permission to set you up for SUCCESS? *
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