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Coaching Intake
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Name
Your answer
Height
Your answer
Weight
Your answer
Email
Your answer
Phone number
Your answer
In general, what are your goals? Check all that apply.
Lose weight/fat
Gain weight
Maintain weight
Add muscle
Improve overall health
Improve physical fitness
Look better
Feel better
Have more energy and vitality
Healthy aging
Get control of eating habits
Get stronger
Physique competition/modeling
Improve athletic performance
Get off or decrease medications
Other:
How, specifically, would you like your habits, your health, your eating, and/or body to be different?
Your answer
Out of all the changes you'd like to make, which ones feel most important/urgent
Your answer
Have you tried anything in the past (or recently) 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, and why? (Even just a little bit, and even if you might not be doing them right now.)
Your answer
Which of those things didn't work well for you and why not?
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/nutritional habits.
Horrible
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10
Awesome!
Clear selection
Why did you pick this number?
Your answer
Right now, how much do the people and things around you support health, fitness, and/or behavior change?
Not at all
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10
Completely
Clear selection
What does your movement look like through the week? Are you working out, going for walks, playing sports, etc?
Your answer
What does your movement look like at work?
Your answer
On a scale of 1-10, how would you rank your health right now?
Worst
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2
3
4
5
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9
10
Awesome!
Clear selection
Why did you pick this number?
Your answer
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
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10
My life is perfectly calm and relaxed
Clear selection
Given all the demands of your life, what is your typical stress level on an average day?
No stress
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10
Extreme stress
Clear selection
On average, how many hour per night do you sleep?
4 or fewer hours
5 hours
6 hours
7 hours
8 hours
9 hours
10 or more hours
Clear selection
How do you normally cope with your stress?
Your answer
How READY are you to change your behaviors and habits?
Not at all
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10
Completely
Clear selection
How WILLING are you to change your behaviors and habits?
Not at all
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10
Completely
Clear selection
How ABLE are you to change your behaviors and habits?
Not at all
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10
Completely
Clear selection
Are you READY, WILLING and ABLE to communicate openly and honestly with me, track your food intake consistently and complete a 30 minute weekly video check-in?
Not at all
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8
9
10
Completely
Clear selection
What do you expect from me as your coach?
Your answer
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