Online Coaching Evaluation

Wellness Evaluation Form

All information obtained is completely confidential..
E-mail
example@example.com
Full Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Best Form of Contact
Birth Date

MonthDayYear
Height (feet/inches)
Weight (lbs)
How did you hear about us?

How much weight do you think you need to LOSE/GAIN?
Why do you want to LOSE/GAIN this weight?
What other programs/products have you tried in the past?
Why do you feel that these other program(s) did not work?
What is your biggest struggle when trying to LOSE/GAIN weight?
How many times a day do you eat?
Are you active during the day?
What time do you normally exercise?
Do you take vitamins or any type of nutritional supplements currently?
How many ounces of water do you drink daily?
Do you eat out? How often? (Times/week)
Where is your energy level, on a scale of 1 to 10? (1: Dragging / 10: Bouncing)
Are you currently taking any prescription medication?
Do you regularly exercise? If YES, what type and how often?

Your Typical Daily Diet
What time do you usually wake up?
BREAKFAST (Eat & Drink)
LUNCH (Eat & Drink)
DINNER (Eat & Drink)

GOALS: WHY do you want to accomplish this? Be as SPECIFIC, DETAILED, and VAIN as possible. How do you want your body to look and feel? Which model, actor/actress, or anyone do you want your body to look like? Do you want more confidence? Do you want to be secure in your own body? Really think about this thoroughly.
Should be Empty: