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Initial Assessment - 4U Health and Nutrition
Congratulations on taking the first step towards a healthier lifestyle! I look forward to getting to know about the unique person that YOU are. There are a few fields that "must" be filled out. Beyond that, share as much or as little as you choose... around here, we like to keep things uncomplicated. Keep in mind, the more you share about your unique situation, the better I can assess how we might approach this journey together. Are you ready to become unstoppable?!
Once you have completed the assessment form, 4U will contact you to set up a consultation and discuss your unique needs. Completing this form does not obligate you to work with 4U Health and Nutrition.
* 5-30min to complete form - depending on the amount of information you are ready to share*
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Email
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Your email
First and last name
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Your answer
Date of birth
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MM
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DD
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YYYY
Height (ft ' inches) and weight (pounds)
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Your answer
Biological sex
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Male
Female
Best phone number to reach you at xxx-xxx-xxxx
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Your answer
How would you prefer me to contact you?
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Email
Text
Phone call
Video chat (FaceTime, Skype, Other)
Other:
Required
What would you like to achieve? Check all that apply.
weight/fat loss
weight gain
improve overall health
improve physical fitness
look and feel better
have more energy
stress management
better sleep habits
decrease dependency on medications
establish better eating habits /meal planning / find healthy recipes
prepping for a specific event (ie: 5K, family hiking vacation, etc)
Other:
Of the items checked above, which feel the most urgent? Please list your top 3 below.
Your answer
Do you currently track your calorie intake / meals? If yes, about how many calories are you consuming each day?
Your answer
If YES to the above, what APP or other tool do you use to track your meals?
Your answer
How many meals / snacks do you typically consume a day? Elaborate if necessary
Your answer
Walk me thru your typical day (high level). Do you work from home? Commute? Where do you consume most meals? When do you consume them? How do you feel when eating (rushed? stressed? relaxed? other?)
Your answer
If you work from home on specific days, please let me know which days. This is helpful so I can customize certain habits for days where you have more flexibility.
Your answer
What (if anything) have you tried in the past to improve your overall health, change habits or improve eating?
Your answer
Which of those things worked well, and why?
Consider everything, no matter how small. Even if you are not doing it anymore.
Your answer
Which of those things didn't work well for you and why not?
Your answer
If you were to consider making more changes to your health, habits and body, what might those things be?
Your answer
Until now, what has stopped you from making those changes?
Your answer
Do you utilize any of the following trackers (check all that apply)
Fitbit
Apple Watch
Garmin Watch
Withings Health Mate
Other
How would you rank your overall nutrition / eating habits?
☠️
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🤩
Clear selection
Tell me more about why you ranked your nutrition and eating habits the way you did above.
Your answer
Do you have any known food allergies or intolerances? If so please elaborate below.
Your answer
Are you active in exercise or sports weekly?
Less than 5 hours
5-9 hours
10-14 hours
15-19 hours
+20 hours
Clear selection
Tell me about the types of exercise / sports that you typically participate in.
Your answer
About how many hours a week do you do other types of physical activity (walking, gardening, playing with your kids, home repairs etc)?
Less than 5 hours
5-9 hours
10-14 hours
15-19 hours
+20 hours
Clear selection
Who lives with you? Check all that apply.
Spouse / partner(s)
Children
Roomate(s)
Pet(s)
Other (extended family, siblings, random squatters)
If you have children (fur-babies count!) what are their names and ages?
Your answer
Who does most of the grocery shopping? Check all that apply.
Me
Spouse or partner
Children
Hired help
No one. I / we always eat out.
Other
Who does most of the cooking in your home? Check all that apply.
Me
Spouse or partner
Children
Hired help
No one. I / we always eat out.
Other
Who selects most of the menus / meal types in your home? Check all that apply.
Me
Spouse or partner
Children
Hired help
No one. I / we always eat out.
Other
Currently, how much do those around you support your health and nutrition goals?
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💯
Clear selection
Right now, do you have specific health concerns such as illness, pain or injuries that I should be aware of?
*Note: Treating, diagnosing or addressing medical conditions is outside the scope of practice for 4U Health and Nutrition. However, understanding the unique intricacies of YOU will allow me to better guide you.
Yes
No
I'm not sure
Clear selection
If yes to the above, please elaborate.
Your answer
Are you currently on any medications or supplements?
Think about prescriptions like birth control or heart medication as well as over the counter products like probiotics, multi vitamins, etc. *Note: Treating, diagnosing or addressing medical conditions is outside the scope of practice for 4U Health and Nutrition. However, understanding the unique intricacies of YOU will allow me to better guide you.
Yes
No
Clear selection
If yes to the above, please elaborate.
Your answer
How would YOU rank your overall health right now?
☠️
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9
10
🏆
Clear selection
How do you spend your week? Check all that apply.
Full time employment
Part time employment
Homemaker / Stay-at-home spouse
Student
Volunteer work
Mostly sedentary at the office
My job requires physical activity
Caring for others (elderly parents, children, etc)
Other:
Given the demands on your life, what is your stress level on a typical day?
low
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high
Clear selection
On average, how many hours do you sleep each night?
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Clear selection
How do you typically cope with stress?
Your answer
What do you expect from me as your Coach? Please be as detailed and specific as possible.
Your answer
What are you prepared to do to work towards your goals? Is there anything that you feel you are unwilling or unable to do?
Your answer
Are there any obstacles that you believe may hinder you from achieving your goals?
Your answer
What else would you like me to know about YOU and your current situation?
Your answer
WHAT IS YOUR WHY? Think about what your reason(s) are for wanting to make lifestyle changes. I am excited to understand more about what brought YOU here. This is a required field... but it's OK to say "I don't know"... we can explore it together!
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Your answer
DISCLAIMER: It is your responsibility to work directly with your health care provider before, during, and after seeking health and nutrition coaching. Guidance 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.
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