Date of Birth
Email *
Phone
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
What types of sports and / or exercise do you typically do?
What other types of movement and / or activities do you do?
If you have children, how many and what are their ages?
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?
