8-Week Nutrition Course

Tell me more about yourself

By learning more about your lifestyle and your habits, I can take better care of you and make sure coaching is a good fit for your goals and individual needs.

Date of birth *

Gender *

Height (cm) *

Current weight (kg) *

Staying in touch

Mobile phone *

Home phone (optional)

How do you prefer me to contact you? *

Emergency contact name *

Emergency contact phone *

What do you want?

In general, what are your goals? Check all that apply.

My goals *

Other goal (optional)

What do you want to change?

How, specifically, would you like your habits, your health, your eating, and / or your body to be different? *

Most important / urgent change #1 *

Most important / urgent change #2

Most important / urgent change #3

Have you tried anything in the past (or recently) to change your habits, health, eating, or body? *

Which of those things worked well, and why? *

Which of those things didn't work well, and why not? *

If you were to make more changes in the future, what might those be? *

Until now, what has blocked you or held you back from changing these things? *

What are you doing right now?

Rank your overall eating / nutrition habits (1 horrible — 10 awesome) *

Why? *

Are you regularly active in sports and / or exercise? *

If yes, approximately how many hours per week? *

What types of sports and / or exercise do you typically do? *

Approximately how many hours per week do you do other physical activity? (housework, walking, gardening…) *

What other types of movement / activities do you do?

What's around you?

Who lives with you? *

Do you have children? If yes, how many and what are their ages? *

Who does most of the grocery shopping? *

Who does most of the cooking? *

Who decides on most of the menus / meal types? *

How much do the people and things around you support health, fitness, and / or behavior change? (1-10) *

What's your health like?

Have you been diagnosed (currently or in the past) with any significant medical condition(s) or injuries? Please describe (write 'None' if not applicable). *

Right now, do you have any specific health concerns, illnesses, pain, or injuries? (write 'None' if not applicable) *

Right now, are you taking any medications (OTC or prescription)? Please list (write 'None' if not applicable). *

How would you rank your health right now? (1-10) *

Why? *

How are you spending your time?

In an average week, how many hours do you spend… (enter 0 if not applicable)

Paid employment *

School or school work *

Traveling / commuting *

Caring for others *

Other unpaid work (housework, errands) *

Volunteering *

How do you feel about your schedule and overall busy-ness? (1 panicked — 10 perfectly calm) *

How is your stress and recovery?

Typical stress level on an average day (1 none — 10 extreme) *

On average, how many hours per night do you sleep? *

How do you normally cope with your stress? *

How ready, willing, and able are you to change?

How READY are you to change? (1-10) *

How WILLING are you to change? (1-10) *

How ABLE are you to change? (1-10) *

What do you expect?

What do you expect from me as your coach? *

What are you prepared to do to work towards your goals? *

Disclaimer

Please recognize that it is your responsibility to work directly with your healthcare provider before, during, and after seeking nutrition and / or fitness consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.

I have read and agree to the disclaimer above *

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