How did you hear about us? *
How do you prefer we contact you? *
Emergency Contact Number *
Which options are of HIGHEST importance to you? *
How specifically, would you like your habits, your health, your eating, and/or your body to be different? *
Out of all the changes you would like to make, which ones feel most important/urgent? Pick your top three *
Have you tried anything in the past (or recently) to change your habits, your health, your eating and/or your body? If so, explain.*
Which of those things worked well for you, and why? *
Which of those things didn't work well for you, and why? *
If you were to consider maybe making more changes to your habits, health, your eating, and/or your body, what might those be? *
Until now, what has blocked you/held you back from changing these things? *
Right now, how would you rate your overall eating and nutrition habits (1-10) and why? *
Are you regularly active in sports/exercise? *
If so, How many hours per week?
What types of sports/exercise do you typically do? *
Approximately how many hours a week do you do other types of physical activity? (eg. housework, walking to work/school, home repair, moving around at work, gardening)*
What other types of movement and/or activities do you do?*
If you are working with us, what time would your ideal time slot be? *
How many days are you committed to per week?*
If you have children, 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? *
Right now, how much do the people and things around you support health, fitness and/or behavior change?*
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries? *
Right now, do you have any 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 rate your health right now? *
In an average week, where do you spend the majority of your time? *
Adding up all of these things, how many total hours per week do you spend doing all these activities? *
On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?*
Given all the demands of your life, what is your typical stress on an average day (1-10)?*
On average, how many hours do you sleep per night? *
How do you normally cope with your stress?*
On a scale of 1-10 how READY are you to change your behavior and habits?*
On a scale of 1-10 how WILLING are you to change your behaviors and habits?*
On a scale of 1-10, how ABLE are you to change your behaviors and habits? *
What do you expect from me as your coach? *
What are you prepared to do to work towards your goals? *
Tell us a bit more about how your preferred eating style looks*
Send in my Questionnaire!
