WELLNESS EVALUATION
What would you like help with? (May choose more than one)
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Nutrition
Gut Health
Mood
Stress/Anxiety
Sleep
Energy
Immune Support
Focus and productivity
Mindset and Confidence
Fitness
Do you feel that you receive balance nutrition daily from the foods you eat?
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Yes
No
Do you eat 3 meals per day?
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Yes
Sometimes
Never
Do you eat breakfast?
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Yes
Sometimes
Never
Do you eat out often? (Ex. Restaurants/fast food)
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Yes
No
Occasionally
How would you describe your energy levels?
*
Excellent
Ok
Up & down
Lethargic
Would you like to improve your energy levels?
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Yes
No
Are you satisfied with your WEIGHT?
*
Yes
No
Are you satisfied with your HEALTH?
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Yes
No
What is your healthy goal?
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Lose Fat/Tone Up
Gain Healthy Weight
More Energy
Wellbeing
3. Do you ever participate in sport or exercise?
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Daily
Weekly
Rarely
Never
Please list the physical activities that you participate in outside of the gym and outside of work.:
If you have any diagnosed health problems please list the condition(s).
If you have any injuries, please list them.
Please list any allergies you have or anything else you think we should know:
Your current diet could be best characterized as:
Low-fat
Low-carb
High-protein
Vegetarian/Vegan
No special diet
Do you Snack?
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Yes
No
How much water do you drink?
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Less than a 1L
between 1-1.5L
Over 1.5L
Do you drink coffee
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Yes
No
How many coffees per day?
Have you ever tried any Nutrition programs? If so which ones?
Are you taking any supplements? Which ones?
Are you currently pregnant or breast feeding?
What is your favourite food?
What are your top 3 health goals and why? Ex. 1. lose weight 2. Gain energy 3. tone up
*
How often do you drink alcohol?
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Are you experiencing any stresses or motivational problems?
Yes
No
On a scale of 1-10 How serious are you about achieving your goal?
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1
2
3
4
5
6
7
8
9
10
Curious
Very serious
1 is Curious, 10 is Very serious
What are your expectations of me as your Coach?
What's stopping you from reaching your goals?
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Lack of motivation
Don’t know how to do things properly or what to do
Not having accountability / support
Emotional eating
Finances
Other
Full Name
*
First Name
Last Name
Place of work / Employer
*
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Birthdate
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
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