Health and Wellness Consultation Questionnaire

Full Name

First NameLast Name

Gender

Date of Birth

MonthDayYear

Age

years

Height

Ft & In

Weight

LBS

What do you do for a living?

Whats the activity level at your job?

Do you follow a regular working schedule, do you work days, afternoon or nights?

How often do you travel?

Please list the physical activities that you participate in outside of the gym and outside of work.:

Have you been diagnosed with any health problems? Please list the condition(s) below

Are you experiencing any stresses or motivational problems? If YES please list them below

Do you have any injuries? If yes please list them below

What additional therapies are being undertaken for the given injury?

Do ANY diseases run in your family? If YES please list below

Are you a current cigarette smoker?

Your current diet could be best characterized as:

Have you had ANY form of weight loss surgires? If Yes, please list surgery type and date of surgery.

Please rate your readiness for change.

What do you consider your BIGGEST health and wellness challenge(s) right now? Choose all that apply.

Explain Other

What do you feel is the biggest obstacle holding you back from overcoming your pain points? Choose all that apply

Explain Other

What are your favorite ways to learn when it comes to your health and wellness? Choose all that apply

Explain Other

What is your biggest frustration or fear when it comes to your health and wellness goals? What do you expect from me as your health and wellness coach?

TImeline for achieving your goal.

Rows	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR	NO TIME LIMIT
NOW

Please rate your motivational level to do what it takes for reach your goal.

Best form of contact?

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com