The Foundational Health Questionnaire
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
What value do you place on your overall health? Physical? Mental? Spiritual?
How do you think your look physically? Muscle tone; flexibility; strength; endurance?
What is your physical activity level? What Type? How often?
How well do you control your emotions and feelings?
Do you listen to the warning signs of your body? For example, if you have pain, do your rest and stop working?
Do you get adequate rest and sleep? Do you sake up refreshed in the morning or still fatigued?
Do you have a balanced life: focusing on yourself and others?
How much mental (brain) potential are you currently using? Are you focused on personal development and improvement?
Overall, how happy are you with your life?
What type of diet do you follow?
Do you drink Alcohol? What type? How often?
Chronic Conditions?
Medications?
Daily Supplements?
What is the immediate need that drew you to Health Coaching?
What are your Goals as a Wellness Coaching Client?
Who can we thank for referring you?
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