Coaching assessment
Tell me more about yourself. By learning more about YOU I can take better care of you and make sure coaching is a good fit for your needs.
Email address *
Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Mobile Phone *
Your answer
Address *
Your answer
Emergency contact name *
Your answer
Emergency contact number
Your answer
What are your goals? Check all that apply *
Required
List all of your concerns about your health, eating habits, fitness and / or body. *
Your answer
Out of all the above concerns, which ones feel more important / urgent? *
Your answer
Why? *
Your answer
What do you expect from me as your coach? *
Your answer
What are you prepared to do to work towards your goals? *
Your answer
Have you tried anything in the past to change your habits, your health, your eating, and / or your body? *
If so, what? *
Your answer
Which of those things worked well for you? *
Your answer
Which of those things didn't work well for you? *
Your answer
How, specifically would you like your habits, your health, your eating, and / or your body to be different? *
Your answer
Have you already made changes to your habits, your health, your eating, and/ or your body recently? *
If so, what? *
Your answer
If you were to consider making further changes to your habits, your health, your eating, and / or your body, what might those be? *
Your answer
Until now, what has blocked you or held you back from changing these things? *
Your answer
Right now how would you rank your overall eating / nutrition habits? *
Horrible
Awesome!!
Why? *
Your answer
Are you regularly active in sport or exercise? *
If so, how many hours per week? *
Required
What type of sports and / or exercise do you typically do? *
Your answer
How many hours a week do you do other types of physical activity? (e.g., housework, gardening, walking, construction)
What other types of movement and / or activities do you do? *
Your answer
Who lives with you? Check all that apply. *
Required
Do you have children? If yes, how many and what are their ages? *
Your answer
Who does most of the grocery shopping in your household? Check all that apply.
Who does most of the cooking in your household? Check all that apply. *
Required
Who decides most of the menus/ meal types in your household? Check all that apply. *
Required
Right now, how much do the people and things around you support health, fitness, and / or behavior change? *
Not at all
Completeley
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries? *
Do you have any health concerns such as illness, pain, or injuries right now? *
Are you taking any medications, either over-the-counter or prescription? *
On a scale of 1-10 where would you rank your health right now? *
Horrible
Awesome
On a scale of 1 to 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
Given the demands of your life, what is your typical stress level on an average day? *
No stress
Extreme
On average, how many hours per night do you sleep? *
How do you normally cope with your stress? *
Your answer
How READY are you to change your behaviors and habits? *
Not at all
Completely
How WILLING are you to change your behaviors and habits? *
Not at all
Completely
How ABLE are you to change your behaviors and habits? *
Not at all
Completely
Where did you hear about us? *
Your answer
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This form was created inside of Pillar Coaching Services.