Pre Assessment Questionnaire
Thank you for considering the HCI Health Coaching Programme! 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.
Email address *
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.
What do you want? In general, what are your goals? Check all that apply.
Please list of all your concerns about your health, eating habits, fitness, and/or body.
Out of all the above concerns, which ones feel most important/urgent?
Why?
What do you expect from the coaching session?
What do you expect from me as your coach?
What are you prepared to do to work towards your goals?
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 worked well for you? (Even if you might not be doing it right now.)
Which of those things didn't work well for you?
Until now, what has blocked you or held you back from changing reaching your health goals?
Right now, how would you rank your overall eating/nutrition habits?
Horrible
Awesome!!!
Clear selection
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?
Approximately how many hours a week do you do other types of physical activity? (e.g. housework, walking to work or school, home repairs, moving around at work, gardening)
Clear selection
What other types of movement and/or activities do you do?
Who does most of the grocery shopping 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
What's your health like? Tick the boxes that apply to you.
On a scale of 1-10, how would you rank your health right now?
WORST
AWESOME!!!
Clear selection
Why do you pick that ranking?
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
How is your stress and recovery?
Think about all the activities you're involved in (e.g., work, school, housework, travel). Then assess as best you can:
Given all the demands of your life, what is your typical stress level on an average day?
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, willing, and able are you to change?
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
Please contact me to arrange a suitable time and date for my complimentary online health coaching session. My WhatsApp Contact No:
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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