Hudson Health Coach - Health Form

Health Survey - Hudson Health Coach
Filling out this form will help me to determine how I can tailor make a plan to fit your individualized needs.

After I receive your questionnaire, I will reach out to you. So please check your spam folder just in case my email gets mislabeled.

Please be honest when answering these questions. I will keep all answers and conversations confidential.
Full Name

First NameLast Name
E-mail
example@example.com
Best number to reach you on
Format: (000) 000-0000.
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
How did you hear about me or our programs?
What would you like to accomplish most with your health right now (lose weight, sleep better, less stress, come off medications, more energy, etc)?
Please describe WHY you are interested in getting healthy. (What is your main motivation? Relationships, activities, how you are feeling (please be specific), etc)
Do you have any food allergies or other allergies that I should be aware of?
Sleep
How many hours of sleep do you typically get?
What time do you typically wake up?
How is your quality of sleep and do you wake up feeling rested?
Hydration
How much water do you drink each day?
Do you consume any other beverages?
Motion
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
Do you currently exercise? If so, how many times a week?
What physical / exercise activities do you participate in?
How would you describe your daily activity level?
Stress
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Are there any other stressors in your life?
Eating Habits
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
Weight
Current Weight: (if you want to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
Height:
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who would like to get healthy with you?
Medical + Background
We can discuss some medical considerations or prescriptions when we chat.
Which of the following applies to you?
Have you used any medically supported weight loss tools?
Are you interested in discussing medically supported options?
How many other weight loss programs have you tried?
Many people have tried everything. If that's you, you're not alone.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country (Required)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Should be Empty:

Health Survey - Hudson Health Coach

Sleep

Hydration

Motion

Stress

Eating Habits

Weight

Medical + Background