Name
*
First Name
Last Name
Email
*
Phone
Primary form of communication is via email unless otherwise specified. This will be for reminders or other special cases.
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Birthday
*
Age used to calculate caloric needs
MM
DD
YYYY
Height
*
Weight
*
Activity Level
*
Sedentary
Lightly Active
Moderately Active
Very Active
Extremely Active
Goals
These will be used as a discussion starter to narrow where to focus first. Please answer honestly for what your desired outcomes are.
Please list all your concerns about your health, eating habits, fitness, and/or body
What do you expect from me as a coach?
What are you prepared to do to work towards your goal?
Have you tried anything in the past to change your habits, health, eating, and/or your body?
What's worked well and what hasn't worked well for you in the past?
How, specifically, would you like your habits, your health, your eating, and/or 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 future changes to your habit,s 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?
Why?
Who do you live with?
Who do you live with?
Who does most of the grocery shopping in your household?
Who does most of the cooking in your household?
Who decides on most of the menus/meal types in your household?
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 illness, pain, and/or injuries?
Yes
No
How do you typically cope with stress?
On average, how many hours per night do you sleep?
How ABLE are you to change your behaviors & habits?
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Anything else you'd like to add?