House of Health by Pamelyn Application

NAME

First NameLast Name
DATE OF BIRTH

MonthDayYear
Date
DATE

MonthDayYear
Date
Current Weight
Current Height
GENDER
EMAIL
example@example.com
MOBILE PHONE
Please enter a valid phone number.Format: (000) 000-0000.
HOME PHONE
Please enter a valid phone number.Format: (000) 000-0000.
What do you want?
In general, what are your goals? Check all that apply

Other (please specify):
What do you want to change?
Out of all of the changes you’d like to make, which ones feel most important / urgent?
Have you tried anything in the past (or recently) to change your habits, your health, your eating, and / or your body? If so, what?
Which of those things worked well for you, and why? (Even just a little bit, and even if you might not be doing them right now.)
Which of those things didn’t work well for you, and why not?
Until now, what has blocked you or held you back from changing these things?
What are you doing right now?
Right now, how would you rank your overall eating / nutrition habits?

1

2

3

4

5

6

7

8

9

10

1 is HORRIBLE, 10 is AWESOME!!!
Are you regularly active in sports and / or exercise?
If so, approximately how many hours per week?
What types of sports and / or exercise do you typically do?
Approximately how many hours a week do you do other types of physical activity? (e.g., housework, walking to work or school, home repairs, moving around at work, gardening)
What other types of movement and / or activities do you do?
Where will you be doing the majority of your workouts?
Do you have any restrictions on the type of weight lifting exercises you are able to do? (Injuries, surgeries, etc.)
How do you feel overall? Anything I should be aware of?
How ready, willing, and able are you to change?

Right now, on a scale of 1-10:
How READY are you to change your behaviors and habits?

1

2

3

4

5

6

7

8

9

10

1 is NOT AT ALL , 10 is COMPLETELY
How ABLE are you to change your behaviors and habits?

1

2

3

4

5

6

7

8

9

10

1 is NOT AT ALL , 10 is COMPLETELY
What do you expect?
How much are you willing to invest per month for a comprehensive program?
What do you expect from me as your coach?
Client signature:
Let's schedule a call so we can talk through the options that will work best for you!
Should be Empty:

What do you want?

What do you want to change?

What are you doing right now?

How ready, willing, and able are you to change?

What do you expect?