Wellness Coaching Initial Consult
Get to know the client before our first meeting to enhance knowledge of lifestyle behaviors and background
What is your first and last name? *
Your answer
What is your phone number and E-mail address? *
Your answer
What is your age, current height and weight?
Your answer
What are your major health and nutrition goals?
Your answer
How would you describe your present state of health?
When was the last time you visited your physician?
Your answer
Please check any that apply to your health *
Required
Have you had any major surgeries?
Your answer
Have you had any past injuries?
Your answer
Describe any other health conditions
Your answer
Has anyone in your immediate family been diagnosed with the following? If so please add whom and relation to you.
Have you had any recent weight changes? If yes please explain.
Have you used any weight loss programs or diets?
What do you consider to be the major issues in your diet and eating plan?
Your answer
How many glasses of water do you drink per day?
How often do you dine out?
Your answer
How often do you prepare meals at home and who prepares them?
Your answer
Do you drink caffeine?
If yes how much?
Your answer
Do you drink alcohol?
If yes, how much per day? per week? per month?
Your answer
Do you smoke?
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service