Health & Fitness Assessment
Please fill out the form below by answering each question. The form will take approximately 3 minutes and 27 seconds to complete.
Emerge Health Coaching
Contact Aimee Frazier with any questions:
First & last name
Email address (this will be used to contact you with your assessment review)
How did you hear about Emerge Health Coaching?
I took the Highbrow course "Weight Management"
I took the Highbrow course "Setting & Achieving Fitness Goals"
I did a web search and found it
I know Aimee in real life
I was referred by someone I know
What areas of your physical health would you like to improve? Select all that apply:
Managing body weight
Toning / building strength
Managing health conditions
Feel more energized
Increase range of motion
What areas of your Mental or Emotional Health would you like to improve? (select all that apply)
Feeling more socially connected to others
Overcoming unhealthy habits
Feeling more spiritually recharged or alive
Finding fulfillment in career or life activities
How would you rate your current diet?
Great! It is very healthy and include veggies, fruits, and I eat natural (non processed foods)
It's alright. I eat a mix of natural (non processed) foods and processed foods
I'd like to make some changes
I have some harmful eating patterns (disordered eating, binge eating, emotional eating)
What is your current level of activity?
Somewhat active. Exercise 1-2 times per week
Active. Exercise 3-4 times per week
Athlete / very active. Exercise 5-7 days per week
What is motivating you to make changes in your current lifestyle?
What obstacles might you encounter when working toward your goals? Select all that apply:
Lack of motivation
Lack of support from family and friends
Are you ready to begin taking action on your health goals right now?
I'm not sure yet
Do you have any serious health conditions?
If you have a serious health condition, please describe it below:
What is your age?
Would you like to be added to the emerge email list and receive occasional emails that contain tools for your health and fitness goals?
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