Date of Birth Email * Phone How do you prefer me to contact you? In general, what are your goals? Check all that apply Please list your biggest concerns about your health, eating habits, fitness, and / or body. Which ones feel most important / urgent? Why? 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? Are you regularly active in sports and / or exercise? Yes or No Yes No If so, approximately how many hours per week? What types of sports and / or exercise do you typically do? Approximately how many hours a week do you do other types of physical activity? (e.g., housework, walking to work or school, home repairs, moving around at work, gardening) What other types of movement and / or activities do you do? Who lives with you? Check all that apply If you have children, how many and what are their ages? Who does most of the grocery shopping in your household? Check all that apply. Who does most of the cooking in your household? Check all that apply Who decides on most of the menus / meal types in your household? Check all that apply 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 Why? Describe your schedule on an average week. ( e.g. work, school, taking care of others, housework, travel/commuting, volunteering) Adding up all these things, how many total hours per week do you spend doing all these activities? On average, how many hours per night do you sleep? How do you normally cope with your stress? Do you have any known / diagnosed food allergies or intolerances? If yes, what are those? Do you have any suspected or possible food allergies or intolerances? If yes, what are those?