Wellness Consult & Goal Setting Questionnaire with Shanie Matthews
Please answer the following to the best of your ability.
Personal Information
Full Name
First Name
Middle Name
Last Name
Age
Sex
Please Select
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Questions and Details
How did you learn about my Personal Trainer/Yoga Therapy services.
Describe yourself in few words.
What do you want us to achieve together? What are your specific wellness goals?
Everyone has aspects in life that can derail their success. What obstacles do you see potentially standing in your way?
How often would you like to do private coaching to achieve your goals?
What time of day do you most enjoying doing activity?
Who is your support system? Who is going to hold you accountable and be there for you when the going gets tough? (If you are ensure, know that I am here to support you every step of the way.)
How long has it been since you felt your best? What were you doing then and who were you doing it with?
What triggers in the past stop you from taking care of yourself.
Do you have areas of your body that are in constant pain? If so, what part of the body? Where on a pain scale of 1 to 10 would you place the level of pain? Are there any injuries that affect you?
One last question...How will your life look when you succeed at your goal? How will you feel? How will your life change? What will you do?
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: