First Name
Last Name
Email
Phone
Age
If you selected "Other" above, please specify:
What do you do for a living?
Please list all of your concerns about your health, eating habits, fitness, and / or body.
Out of all of the above concerns, which 2 or 3 feel most important / urgent?
Why are these 2-3 concerns so important / urgent??
What do you expect from me as your coach?
What are you prepared to do to work towards your goals?
Have you tried anything in the past to change your habits, your health, your eating, and / or your body? If so, what?
Which of those things worked well for you? (Even if you might not be doing it right now.)
Which of those things didn’t work well for you?
How, specifically, would you like your habits, your health, your eating, and / or your body to be different?
Have you already made changes to your habits, your health, your eating, and / or your body recently? If so, what?
If you were to consider making further changes to your habits, your health, your eating, and / or your body, what might those be?
Until now, what has blocked you or held you back from changing these things?
Right now, how would you rank your overall eating / nutrition habits? (If 1 is Horrible and 10 is Awesome.)
Why did you rank yourself the number above?
Are you regularly active in sports and / or exercise? Yes No
What types of sports and / or exercise do you typically do?
What other types of movement and / or activities do you do?
Do you have children? If yes, how many and what are their ages?
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 (e.g. parent, grandparent, sibling, etc.)
Right now, how much do the people and things around you support health, fitness, and / or behavior change? (If 1 is "Not At All" and 10 is "Completely".)
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries? Yes No
Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries? Yes No
Right now, are you taking any medications, either over-the-counter or prescription? Yes No
On a scale of 1-10, how would you rank your health right now?
Why did you rank your health the above number?
In an average week, how many hours do you spend in paid employment?
In an average week, how many hours do you spend traveling and / or commuting?
In an average week, how many hours do you spend taking care of others? (e.g., children, person with a disability, older person)
In an average week, how many hours do you spend doing other unpaid work? (e.g., housework, errands)
In an average week, how many hours do you spend volunteering?
In an average week, how many hours do you spend at school or doing school work?
Adding up all these things, how many total hours per week do you spend doing all these activities?
On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?
Think about all the activities you’re involved in (e.g., work, school, caregiving, housework, travel). Given all the demands of your life, what is your typical stress level on an average day? (If 1 is "No Stress" and 10 is "Extreme Stress".)
How do you normally cope with your stress?
How READY are you to change your behaviors and habits? (If 1 is "Not At All" and 10 is "Completely".)
How WILLING are you to change your behaviors and habits? (If 1 is "Not At All" and 10 is "Completely".)
How ABLE are you to change your behaviors and habits? (If 1 is "Not At All" and 10 is "Completely".)
AGREE AND SUBMIT
