1024 Wellness Consultation Questionnaire

1024 Wellness Consultation Questionnaire
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Height
Weight
lbs.
What are your goals?

Lose weightGain weightMaintain weightGet control of eating habitsHave more energyImprove physical fitness
What's the activity level at your job?

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
If you have any injuries, please list them.
Please list all of your concerns about your health, eating habits, fitness, and/or body.
Are you experiencing any stresses or motivational problems?

YesNo
How do you normally cope with stress?
Your current diet could be best characterized as:

Low-fatLow-carbHigh-proteinVegetarian/VeganNo special diet
Please list any food allergies/dislikes:
How much sleep do you usually get each night?
How often are you willing to train a week to reach your goal?
Please rate your readiness for change.

1(Not at all)2345678910(Completely)
Please rate your motivational level to do what it takes for reach your goal.

12345678910
What do you expect from me as your coach?
What is your biggest motivation for making changes to your diet and lifestyle?
ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and/or fitness consultation. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.

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