Initial Assessment & Health History Questionnaire
Please complete the following as accurately and completely as possible
About You
By learning about your lifestyle and habits, I can take better care of you and make sure that coaching is a good fit for your goals and individual needs.
Name (first and last) *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Spouse/Significant Other's Name *
Your answer
Staying in Touch
Email (This is used to confirm appointments and send reminders so please use an email you check frequently) *
Your answer
Mobile Phone (with area code) *
Your answer
Other contact phone
Your answer
How do you prefer me to contact you? *
Goals/Concerns
In general, what are your goals? Check ALL that apply. *
Required
Please list all of your concerns about your health, eating habits, fitness and/or body *
Your answer
Out of those concerns listed above, which one(s) feel most important or urgent? *
Your answer
What makes it/them important/urgent to you? *
Your answer
Expectations
What do you expect from me as your health/nutrition coach? *
Your answer
What are you prepared to do to work toward 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? (Even if you might not be doing them now) *
Your answer
Which of those things did NOT work well for you? *
Your answer
How would you like your habits, your health, your eating and/or your body to be different? Be specific. *
Your answer
Have you already made changes to your habits, your health, your eating and/or your body recently? If so, what has changed?
Your answer
If you were to consider making further changes to your habits, your health, your eating and/or your body, what might those changes be? *
Your answer
Until now, what has blocked you or held you back from changing this/these? *
Your answer
Right now, how would you rank your overall eating/nutrition habits? *
Horrible
Awesome
Why? *
Your answer
Are you regularly active in sports and/or exercise? *
If so, how many hours per week?
What types of sports/exercise do you typically do?
Your answer
Approximately how many hours per week do you do other types of physical activity? (e.g. housework, walking to/from wok, home repairs, moving around at work, gardening) *
Describe these others forms of movement/activities *
Your answer
Lifestyle & Environment
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 *
Required
Who does most of the COOKING in your household? Check ALL that apply *
Required
Who decides on 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 your health, fitness and/or behavior change? *
Not at all
Completely
Health
Have you been diagnosed (currently or in the past) with any significant medical condition and/or injuries? *
If yes, please list.
Your answer
Right now, do you have any specific health concerns such as illnesses, pain, and/or injuries? *
If yes, please list.
Your answer
Are you currently taking any prescription or over the counter medicines? *
If yes, please list dosage, strength and frequency
Your answer
On a scale of 1-10, how do you rank your health right now? *
Horrible
Awesome
Why? *
Your answer
Time Management
Think about your weekly commitments and answer the following...
In an average week, how many hours do you spend... *
5 or less
6-10
11-15
16-20
21-25
26-30
31-35
36-40
More than 40
In paid employment
At school or doing school work
Traveling and/or commuting
Taking Care of Others
Doing unpaid work (e.g. housework/errands)
Volunteering
Adding up all hours above, how many total hours per week do you spend doing ALL these activities? *
Your answer
On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness? *
My life is chaotic
My life is perfectly calm and relaxed
Stress and Recovery
Think about all the activities you're involved in (e.g., work, school, caregiving, housework, travel). Then assess as best you can.
Given all the demands of your life, what is your typical stress level on an average day? *
No Stress
Extreme Stress
On average, how many hours per night do you sleep? *
How do you normally cope with your stress? *
Your answer
Ready, Willing, Able
Right now, on a scale of 1-10:
How READY are you to change behaviors and habits that keep you from your goals? *
Not at all
Completely
How WILLING are you to change behaviors and habits that keep you from your goals? *
Not at all
Completely
How ABLE are you to change behaviors and habits that keep you from your goals? *
Not at all
Completely
Please explain any hesitation to being READY, WILLING or ABLE *
Your answer
Disclaimer
Health/wellness and/or nutrition coaching is not intended to diagnose, treat, prevent or cure any disease or condition. It should not be a substitute for the advice, treatment and/or diagnosis of a qualified licensed professional. Certified Health or Nutrition coaches may not make any medical diagnosis, claims, or substitute for your personal physician's care. As your health/wellness/nutrition coach, I do not provide a second opinion or in any way attempt to alter the treatment plans or therapeutic goals of your personal physician or healthcare team. It is my role to partner with you to provide ongoing support, resources and accountability as you create an action plan to meet and maintain your health goals.
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