Initial Assessment Questionnaire
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Name *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Height *
Weight in KG *
Phone *
In general, what are your goals? Check all that apply. *
Required
If your goal is weight loss, how much weight do you want to lose? *
How, specifically, would you like your habits, your health, your eating, and / or your body to be different? *
Out of all of the changes you’d like to make, which ones feel most important / urgent? *
If you were to consider maybe making more changes to your habits, your health, your eating, and / or your body, what might those be? *
Dietary preference *
How many meals per day fits in with your lifestyle? *
Right now, how would you rank your overall eating / nutrition habits? *
Horrible
Awesome!
Are you regularly active in sports and / or exercise?If so, approximately how many hours per week? *
What types of sports and / or exercise do you typically do? *
How would you describe your daily activity? *
Who lives with you? *
Do you have children? If yes, how many and what are their ages? *
Who does most of the grocery shopping in your household? *
Who does most of the cooking in your household? *
Who decides on most of the menus / meal types in your household? *
How many times a week would you eat out / takeaway? *
Right now, how much do the people and things around you support health, fitness, and / or behaviour change? *
Not at all
Completely
Have you have been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries? *
Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries? *
Right now, are you taking any medications, either over-the-counter or prescription? *
On a scale of 1-10, how would you rank your health right now? *
Worst
Awesome!
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
Given all the demands of your life, what is your typical stress level on an average day? *
No stress
Extreme Stress
How do you normally cope with your stress? *
On average, how many hours per night do you sleep? *
How READY are you to change your behaviours and habits? *
Not at all
Completely
How WILLING are you to change your behaviours and habits? *
Not at all
Completely
How ABLE are you to change your behaviours and habits? *
Not at all
Completely
What do you expect from me as your coach? *
What are you prepared to do to work towards your goals? *
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