Name
*
First Name
Last Name
Age, Weight and Height
Email
*
In general, what are your goals?
*
lose weight/fat , gain weight, maintain weight, add muscle, improve physical fitness, look better, feel better etc
What are you prepared to do to work towards your goals?
Have you already started to make changes to your habits, health, eating and/or body? If so, what are you doing?
Please list all your concerns about your health, eating habits, fitness, and/ or body.
How specifically would you like your habits, your health, your eating, and/or your body to be different?
Please describe your average day of eating. Be as specific as possible.
Please give me some details; how long you've been doing it, etc.
What are some of your favorite foods?
What are some foods you DO NOT like?
If you're less consistent than you'd like to be; what knocks you off track?
Any food allergies or intolerances?
How often do you have a bowel movement?
More than 3 times daily
2 - 3 times daily
1 - 2 times daily
Once every two to three days
A few times a week
Weekly or less
Do you feel like you have trouble controlling you appetite?
Do you struggle with food cravings?
IF yes, what do you crave and when?
Do you notice any connection between your emotions and your eating habits?
Have you noticed any connection between stress and your eating habits?
How often do you think about food and eating?
Please choose the option that fits best.
How often do you eat to the point of being full or stuffed?
You can choose more than one here.
If you feel like you've eaten too much, what do you do afterwards?
Check ALL that apply.
How often do you skip meals or purposely go a long time without eating?
Daily
Often
Sometimes
Rarely
Never
How often do you cook at home?
0 meals a day
1 to 2 meals a day
3 to 4 meals a day
all meals prepped at home
How often do you eat out?
0 times per week
1 to 2
3 to 4
5 or more days per week
How often do you go grocery shopping?
Do you like cooking?
How many hours of week do you exercise
Thinking about all you have written here, what do you think you'd like to work on or address first?
What do you expect from me as your coach?
What are some of the biggest obstacles that you find stand in your way?
Who are you around ? Do they support your health/fitness behavior change?
On a scale of 1-10 how busy are you daily?
1 being packed and insane 10 being perfectly calm and relaxed
Given all the demands of your life, what is your typical stress level on an average day?
1 = no stress 10 = extreme stress
How do you normally cope with stress?
On average, how many hours do you sleep per night?
On a scale of 1-10 how ready are you to change your behaviors
1= not at all 10 = completely
On a scale of 1-10 how willing are you to change your behaviors and habits?
On a scale of 1-10 how able are you to change your behaviors and habits?
