Health Coaching Intake Form

  • Health Coaching Intake Form

    Anchor of Hope Counselling & Wellness
  • Date
     - -
  • Format: (000) 000-0000.
  • How do you prefer me to contact you?

  • What Do You Want?

  • In general, what are your goals? Check all that apply.

  • What Do You Want To Change?

  • What Are You Doing Right Now?

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  • Are you regulary active in sports and / or exercise? If so, approximately how many hours per week?
  • 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's Around You?

  • Who lives with you? Check all that apply.
  • Who does most of the grocery shopping in your household? Check all that apply.
  • Who decides on most of the menus / meal types in your household? Check all that apply.

  • What's Your Health Like?

  • Have you been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries?
  • Right now, do you have any specific health concerns, such as illnesses, pain and / or injuries?
  • Right now, are you taking any medications, either over-the-counter, prescription or supplements?

  • How Are You Spending Your Time?

  • In an average week, how many hours do you spend...
    In paid employment?      
    Taking care of others:      
    At school or doing school work?     
    Doing other unpaid work? (housework, errands)     
    Traveling and / or communting?     
    Volnteering?      

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  • How Is Your Stress & Recovery?

    Think about all the activities you're involved in (e.g., work, school, caregiving, housework, travel). Then answer as best you can:
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  • On average, how many hours per night do you sleep?

  • How Ready, willing & Able Are You To Change?

    Right now, on a scale of 1 - 10:
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  • What Do You Expect?

  • Disclaimer

    Please recognize that it is your responsibility to work directly with your health care provider before, during and after seeking health, nutrition and / or fitness consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.
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