Pre Assessment Questionnaire
Thank you for considering the S.E.X (Sleep.Eat.eXercise) Program! This self-assessment questionnaire will help us to get to know you better. There are no right or wrong answers, simply answer as accurately as possible, for your unique situation. Once completed, we will contact you via WhatsApp to arrange your complimentary discovery session.
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Email *
Tell me more about yourself.
By learning more about your lifestyle and your habits, we can take better care of you and make sure coaching is a good fit for your goals and individual needs.
1. What do you want? In general, what are your goals? Check all that apply.
2. Please list your top concerns about your health, eating habits, fitness, and/or body.
2. What do you want to change? Have you tried anything in the past to change your habits, your health, your eating, and/or your body? If so, what?
Which of those things didn't work well for you?
3. Until now, what has blocked you or held you back from reaching your health goals?
4. Right now, how would you rank your overall eating/nutrition habits?
Horrible
Awesome!!!
Clear selection
5. Are you regularly active in sports and/ or exercise? If so, approximately how many hours per week?
Clear selection
What types of sports and/or exercise do you typically do?
6. Who does most of the grocery shopping in your household? Check all that apply.
7. Who decides on most of the menus / meal types in your household? Check all that apply.
8. Right now, how much do the people and things around you support health, fitness, and/or behavior change?
Not at all
Completely
Clear selection
9. What's your health like? Tick the boxes that apply to you.
What chronic conditions do you have, if any?
10. On a scale of 1-10, how would you rank your health right now?
WORST
AWESOME!!!
Clear selection
11. 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
12. On average, how many hours per night do you sleep?
Clear selection
13. How ready, willing, and able are you to change to achieve your health goals?
Right now, on a scale of 1-10:
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
Preferred Name: *
Gender:
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Date of Birth: *
MM
/
DD
/
YYYY
Please contact me to arrange a suitable time and date for my complimentary online first health coaching session. My WhatsApp Contact No: *
How did you find out about us? *
If it's a Friend or Others, please specify who or what: *
I prefer a health coach who is: *
Male
Female
No preference
Gender
I prefer a health coach who speaks: *
Chinese
English
Malay
Language
Please recognize that it is your responsibility to work directly with your health care provider before, during and after seeking nutrition and/or health coaching with Health Coach International. 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 responsibility for your decision. *
* All responses will be treated in strict confidence, and will not be divulged to any third party except when analysed as a group without reference to any individual.
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