Health Coaching Intake Form

Please fill out the following form.

First name

Last name

Date of birth

Month

Day

Year

General Health

Have you been hospitalized in the last 12 months?

Yes

Are you suffering from a medical condition, illness or injury?

Yes

If you answered yes to any of the questions above, please supply additional information.

Are you currently taking any medications or supplements? If yes, please list them.

Do you have any known food allergies or intolerances? If yes, please specify.

Tell me about any past or current injuries.

In-Depth Health Review

What is your everyday life like (work/kids/school/other hobbies/commitments)?

Is there a recurring day and time you would like to schedule for our bi-weekly video or phone call? If you don’t want bi-weekly please indicate a frequency that would work for you (you can change this anytime in the future).

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

How would you describe your current stress levels?

How would you describe your overall energy levels throughout the day?

How would you describe your current stress levels?

Low

Medium

High

What are the main sources of stress in your daily life?

What strategies do you currently use to manage stress (exercise, journaling, downtime, etc.)?

Are there habits or routines that help you feel grounded or balanced?

If applicable, do you track your cycle?

If applicable, do you feel your menstrual cycle impacts your daily life and/or training?

Nutrition

Do you currently follow any specific dietary pattern (vegan, vegetarian, gluten free, etc.)?

What does a typical day of meals and snacks look like for you?

How consistent is your daily routine (meals, sleep, schedule)?

Do you track your food intake or any health data (macros, calories, weight, sleep, etc.)?

What foods or eating patterns make you feel your best? What tends to make you feel worse?

Do you experience digestive issues, energy crashes, or strong cravings regularly? If yes, please describe.

How would you describe your current relationship with food?

Do you ever feel guilt, stress, or anxiety around eating?

Have you ever worked with a nutritionist, dietitian, or coach before? If so, what was that experience like?

Do you have any history of disordered eating or restrictive patterns you’d like me to be aware of?

Exercise

Broadly, what is your general athletic history?

What does your typical week look like when it comes to exercise? What would you like it to look like?

What type of gym equipment do you have access to? A full gym, free weights, etc?

General

What are your short-term goals (next 3–6 months)?

What are your long-term goals (6+ months)?

What feels most challenging for you right now when it comes to health and lifestyle habits?

Is there anything else I should know about you?

Initials

I declare that the info I’ve provided is accurate and complete.

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