Name
*
First Name
Last Name
Email
*
Age
*
What do you want?
*
In general, what are your goals? Check all that apply
Please list your concerns about your health, eating habits, fitness and or body.
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Out of the above concerns, which ones feel most important/ urgent and why?
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What do you expect from me as your coach
What are you prepared to do to work towards your goals
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?
Which of those worked well for you?
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 you were to consider making changes what would they be?
Until now what has blocked you or held you back from making changes?
Why do you give yourself this rating?
What sport or activities do you typically do
Do you have children?
Yes
No
Who does most of the grocery shopping?
You? Another family member?
Who does most of the cooking?
You? a Family member? Restaurants?
Have you been diagnosed with any significant medical conditions or injuries?
Yes
No
If yes to above question explain in a few sentences
on average how many hours of sleep do you get each night
4 or fewer hours
5 hours
6 hours
7 hours
8 hours
9 or more hours
How do you normally cope with stress?
