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Nutrition Coaching Questionnaire and Agreement
Please fill out the following form so I can get to know you a bit better. All answers will be kept strictly confidential.
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Your name:
Your date of birth:
MM
/
DD
/
YYYY
What's your gender?
Clear selection
Height and Weight
Email address:
Phone number:
How do you prefer I contact you?
Emergency contact name and relationship to you:
Emergency contact phone number:
In general, what are your goals? Check all that apply.
How, specifically, would you like your habits, your health, your eating, and/or your body to be different?
Out of all the changes you'd like to make, which ones feel most important/urgent? Select your top three.
Have you tried anything in the past (or recently) to change your habits, your health, your eating, and/or your body? If so, what?
Which of those things worked well for you, and why? (Even just a little bit, and even if you might not be doing them right now.)
Which of those things didn't work well for you, and why not?
If you were to consider maybe making more 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?
Right now, how would you rank your overall eating/nutrition habits?
Horrible
Awesome!
Clear selection
Why did you choose that ranking?
Approximately how many hours per week are you involved in sports and/or exercise?
Clear selection
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? (i.e. housework, walking to work/school, home repairs, moving around at work, gardening)
Clear selection
What other types of movement and/or activities do you do?
Who lives with you? Check all that apply
Do you have children? If yes, 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.
Right now, how much do the people and things around you support health, fitness, and/or behavior change?
Not at all
Completely
Clear selection
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries?
Clear selection
Right now, do you have specific health concerns, such as illnesses, pain, and/or injuries?
Clear selection
Right now, are you taking any medications, either over-the-counter or prescription?
Clear selection
On a scale of 1 - 10, how would you rank your health right now?
Worst
Awesome!!!
Clear selection
Why did you give your health that ranking?
In an average week, how many hours do you spend... (if less than 1 hour, leave that section blank)
1 - 10
10 - 20
20 - 40
40 or more
Working?
Take care of others?
At school?
Doing unpaid work?
Commuting?
Volunteering?
Adding up all these things, how many total hours per week do you spend doing all these activities?
On a scale of 1 - 10, how do you feel about your schedule, time use, and overall busy-ness?
My life is panicked and insane
My life is perfectly calm and relaxed
Clear selection
Given all the demands of your life, what is your typical stress level on an average day? Think about all the activities you're involved in (i.e. work, school, caregiving, housework, travel). Then assess as best you can.
No stress
Extreme stress
Clear selection
On average, how many hours per night do you sleep?
Clear selection
How do you normally cope with your stress?
How READY are you to change your behaviors and habits?
Not at all
Completely
Clear selection
How WILLING are you to change your behaviors and habits?
Not at all
Completely
Clear selection
How ABLE are you to change your behaviors and habits?
Not at all
Completely
Clear selection
What do you expect from me as your coach?
What are you prepared to do to work towards your goals?
Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and/or fitness consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.
Clients will be billed for a full months' sessions at the beginning of each month. We require a days' notice for reschedules and refunds. Unfortunately, we are unable to offer reschedules or refunds for last minute cancellations or no-shows.
Thank You for your interest in High Note Performance! Please select a time for your coaching using the link on the High Note Performance webpage (www.highnoteperformance.fit/join)
All times are in half hour increments. For an hour coaching, please select TWO CONSECUTIVE TIME SLOTS. If no slots are available, please contact me at miriam@highnoteperformance.fit
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