Health Coaching Intake Form

Health Coaching Intake Form
Thank you for taking the time and effort to complete this questionnaire. There is no correct answer to any of the following questions. The responses you provide will help us get to know you and ensure we meet your current needs.
Name

First NameLast Name
Date of birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
May we leave voicemail messages that identify the caller as a team member from Whole Medicine?

YesNo
Health goals
What are your main health concerns, and how have they impacted your life?
What are your long-term health goals (6-12 months)?
How motivated are you to reach your goals? (1 - completely unmotivated, 10 - completely motivated)

12345678910
Lifestyle
Do you exercise?

YesNo
If yes, indicate the number of times you exercise during the week, as well as the type of exercise
How many alcoholic drinks do you consume per week?

01-22-44+Other
Do you smoke?

YesNoIn the past
Do you use recreational drugs?

YesNo
Do you eat fast food?

YesNo
If yes, please indicate how often you eat fast food each week.
Do you eat out (excluding fast food)?

YesNo
If yes, please indicate how often you eat out (excluding fast food) each week.
Amount of soda (including diet) you drink in a typical day
How many cups of coffee do you drink per day?

01-22-44+
How many glasses of water do you drink each day?

1-33-56-88+
Please rate your current stress level. (1 - Not stressed at all to 5 - Extremely stressed)

12345
What are your primary sources of stress?
What do you do to relax or relieve stress?
We would like to set up a brief discovery call where we will discuss your health goals, as well as Melissa's approach to health coaching, and complete the next steps to get started. Please select a 15-minute time slot for Melissa to call you.
Thank you so much for providing this information. Melissa will be in touch at your scheduled phone call to discuss next steps. We look forward to working with you!
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Health Coaching Intake Form

Health goals

Lifestyle