Name *

Email *

What is the biggest change you want to make in your health in the next 3 months? *

What's the biggest change you want to make in your life in the next year? *

Check the things that are most important to you. *

What is the most important dream you have had for yourself that you've put off? *

What is keeping you from realizing this dream?

If someone were to write one-sentence story about you, what would they say? *

What are your goals/expectations for coaching? Do you have any questions for me? *

Please let me know about medical history you think I should know? Diabetes, eating disorders, thyroid disorders, depression, injuries, etc. *

On a scale of 1 (poor) to 10 (excellent), how would you rate your satisfaction with your current physical activity level? *

How would you categorize your current activity level? *

Describe your physical activity in the past year (aerobic, muscular strength, &/or flexibility development; include structured classes as well as recreations *

What did you most enjoy? *

What do you want to try? *

Describe current & previous limitations (knee pain, etc.) *

Please list any/all fitness equipment you own and fitness memberships you have: *

Do you have any specific athletic performance goals? *

On a scale from 1 (poor) to 10 (excellent), how would you rate your satisfaction with your current eating habits? *

How would you describe your current eating habits? *

Describe your typical weekday meals (breakfast, lunch, dinner, snacks, meals ordered out): *

Describe your typical weekend meals: *

Please list any food aversions/allergies/dislikes: *

List any weight management programs done in the past 5 years: *

On a scale of 1 (poor) to 10 (excellent), how would you rate your general stress level? *

On a scale of 1 (poor) to 10 (excellent) how would you rate your energy level? *

On a scale of 1 (poor) to 10 (excellent), how would you rate your sleep? *

Please list your height and current body weight: *

On a scale of 1 (poor) to 10 (excellent) how would you rate your satisfaction with your body? *

Describe *

What specific outcomes are you looking for from this coaching experience? Please describe in detail. *

What efforts have you made to create this change in the past month? *

On a scale of 1 (poor) to 10 (excellent), how would you rate your belief in your own abilities? *

Rate your readiness to create this change: *

What other improvements would you like to make in your life? (Consider the areas of: Family/friends, finances, career, service/character, personal growth/learning, spiritual path, home organization, creativity, play/leisure, etc.) *

Have you ever worked with a coach? If so, what worked well for you and what did not work well in the relationship(s)? *

Describe your ideal coach (i.e. nurturing vs. no-nonsense, etc.) *

What approaches discourage or de-motivate you? *

How will you know if you are receiving value from this coaching relationship? *

What else would you like me to know? *