Initial Assessment & Triage Questionnaire
This questionnaire serves as the initial step in building a personalized program to help clients achieve their health and fitness goals. Below is a brief description of its purpose and components:
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Please provide additional information about yourself, including your full name, contact phone number, email address, and your preferred method of communication. Don’t forget to include emergency contact name and phone number
By learning more about your lifestyle and your habits, I can take better care of you and make sure coaching is a good fit for your goals and individual needs. Please provide additional information about yourself, including your gender, date of birth, current height and current weight. 
What are your desired goals: Please check the appropriate boxes if applicable.
What do you want to change: What are your ultimate health and body goals?
Out of all the changes you would like to make, what feels most urgent/ a priority for you? Please List

Have you ever tried anything in the past to change your habits, your health and your eating? Please Explain

Which of the above listed worked well for you? What did not?

Until now, what has held you back from pursuing a change in health habits?

What would you rate your overall eating and nutrition habits on a scale of 1-10?
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What is your reason for giving that number?

Are you regularly active in exercise or sports? If so, how many hours per week?

What types of sports or exercise do you typically do?

Approx how many hours a week do you do other types of physical activity? (Housework, gardening, walking to school etc.)

Who lives with you?

Do you have children? If yes, how many and what are their ages?

Who does most of the grocery shopping in your household?

Who does most of the cooking/meal prep in your household?

Who decides on most of the menus in your household?

On a scale of 1-10 how much do people and things around you support health, fitness, and or behavior change?

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What's Your Health Like

Have you been diagnosed (currently or historically), with any significant medical condition and or injury? Please explain

Currently, do you have any specific health concerns, illnesses, injuries or pain?

Are you taking any medications? OTC or prescription

Please list

On a scale of 1-10, how would you rank your health right now?

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What is your reason for giving that number?
How do you spend your time?
On an average week, how many hours do you spend:

On a scale of 1-10 how do you feel about your schedule, time use and overall busyness?

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What is your reason for giving that number?

How is your stress and recovery?

Given all the demands of your life, what is your stress level on an average day? Rank on a scale of 1-10

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On average, how many hours per night do you sleep?

How do you normally cope with stress?

How ready and willing are you to change?

On a scale of 1-10 how ready are you to change your behaviors and habits?

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How willing are you to change your behaviours and habits?

How able are you to change your behaviours and habits?

What do you expect from me as your coach?

What are you prepared to do to work towards your goals?

Disclaimer: Please recognize that it is your responsibility to work directly with your healthcare provider before, during and after seeking nutrition and/or fitness consultation.


Any information provided is not to be followed without prior approval from your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.


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