Exercise Stages of Change Form

1

Welcome to the Morphoneogenesis LLC Exercise Stages of Change Questionnaire! As part of our Cognitive Behavioral Health services, this form helps us understand where you are in your journey toward integrating physical activity into your life. By identifying your current stage of change, from contemplation to maintenance, we can better support your mental and physical health goals through personalized coaching. Your responses will guide our Health & Wellness Coaching to ensure we provide the most effective strategies for lasting behavioral change. Answer each question thoughtfully to help us tailor our approach to your unique needs and aspirations.

2

Exercise Stages of Change Questionnaire

Morphoneogenesis LLC

Health & Wellness Coaching

3

Name

First Name

Last Name

4

Email

example@example.com

5

Phone Number

Area Code

Phone Number

6

Gender

7

Exercise includes activities such as brisk walking, jogging, swimming, aerobic dancing, biking, rowing, weight lifting, etc. Activities that are primarily sedentary such as bowling, or playing golf with a cart, would not be considered exercise.

“Regular” exercise is defined as 3 or more times each week for at least 20 minutes each time.

8

For each statement, please mark yes or no:

9

1. I am currently physically active (at least 30 minutes per week).

YESNO

10

2. I intend to become more physically active in the next 6 months.

YESNO

11

3. I currently engage in regular physical activity.

YESNO

12

4. I have been regularly physically active for the past 6 months.

YESNO

13

Exercise Stages of Change - Scoring Key

No to 1, 2, 3, and 4 = Pre-contemplation stage
No to 1, 3, and 4, Yes to 2 = Contemplation stage
Yes to 1 and 2, No to 3 and 4 = Preparation stage
Yes to 1 and 3, Yes or No to 2, No to 4 = Action stage
Yes to 1, 3, and 4, Yes or No to 2 = Maintenance stage

14

What is the main obstacle that prevents you from working out regularly?* This field is required.

15

Payment* This field is required.

Cognitive Behavioral Health
Cognitive Behavioral Health of Morphoneogenesis provides a holistic approach to managing and improving health behaviors through integrated services. Our program includes motivational interviewing, which helps clients uncover their personal motivations for change, SMART goal setting for establishing clear and achievable health objectives, and health behavioral management that utilizes cognitive behavioral techniques to foster lasting lifestyle changes.
$50.00 for each month
SUBSCRIBE