Health Coaching Assessment Questionnaire
The information you enter is kept private, is only viewed by Jen Casey, CNP and is solely for the purpose of working together in a Health Coaching relationship
Email address *
Phone number (Not shared! Only for the purpose of our initial phone call and ongoing coaching) *
Your answer
Your age? *
Your answer
What is your definition of "health"? *
Your answer
What form of accountability do you feel would work best for you? *
0 points
What have been your wellness challenges to date? *
Your answer
What have been your health achievements? *
Your answer
How would you rate your knowledge of nutrition? *
not very knowledgeable
very well versed in nutrition and health
List your top 3 health goals *
Your answer
Do you have any health concerns/conditions? (diabetes, allergies, diagnosis, etc)
Your answer
Walk me through what you currently eat in a day *
Your answer
Tell me a bit about your fitness regime *
Your answer
Describe your sleep habits *
Your answer
How would you rate your stress level? *
I don't feel stressed at all
Over the top stressed
How would you rate your commitment to reaching your goals *
I'm not very motivated
extremely ready and willing
Thank you! I look forward to getting started with you. Any other comments before we set up a phone call?
Your answer
What day of the week/time of day is best for us to set up an intro phone call? *
Your answer
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