Wellness Coaching Questionnaire

Full Name*

First NameLast Name

Gender

MaleFemale

Email

example@example.com

Phone Number

Area CodePhone Number

Age

years

Height

cm

Weight

KG

What do you do for a living?

Whats the activity level at your job?

None (seated all day)Moderate (light activity such as walking)High (heavy labor, very active)

How many pounds would you like to lose/gain, or what is your health goal?

What have you tried before and why did it not work for you?

Do you eat 3 meals a day?

YesNo

If so, which meals do you skip?

BreakfastLunchDinner

Do you generally snack?

YesNo

How many days a week do you eat out?

1-33-5over 5never

How much water do you drink daily?

1 glass2-3 glassesfull gallon alwayswhat's water?

What else do you currently drink?

TeaJuiceSodaCoffee/Energy Drinks

When are you the most tired?

Right when I wake upMid-dayAfter workOther

Please rate your readiness for change.

Why?

What do you need the most help with?

AccountabilityJust starting!I've hit a plateau & I need to change thatOther

Are you willing to financially commit to changing your life?*

YesNo

How do you prefer to be contacted?

CallTextEmailOther

I am so excited that you decided to reach out to me to help you with your wellness goals! I can't wait to work with you! I'll reach out within 24 hours!

Wellness Profile!