WEST COAST WELLNESS

WCW

16 Week Health & Wellness Action Plan
Name

First NameLast Name
Height
Current Weight
Age
Gender

MaleFemale
Email
example@example.com
If Coaching goes exactly the way you would like, what would you need to accomplish, work on, and improve on? Our goal is for you to be able to say at the end "coaching was more than successful."
Please list physical fitness goals, lose weight, change body composition, increase muscle mass, lower body fat%, improve consistency, etc. Please explain in detail
Do you have any health conditions that may have an affect health, wellness, life goals?

YesNo
If yes, then please share them below:
Ideally, in the next 90 days what emotional/mental improvements would you like to see? WHAT WOULD NEED TO HAPPEN MENTALLY/EMOTIONALLY FOR YOU TO SAY COACHING WAS A SUCCESS?
How is your sleep? Do you sleep through the night, what time do you go to bed, do you have a routine or does bedtime and wakes-ups shift? On average how many hours of sleep do you get a night?
Do you have a past with eating disorders or addictions, if so, please explain
In the past, what has been the biggest struggle with making progress and/or hitting goals?
What are you willing to do to achieve your goals?
What things are you not flexible with in your health, wellness, life?
What is one food/drink you feel you cannot live without?
How much screen-time do you average a day? Social, phone, tv, ipad etc
Any other things you'd like to share that may be helpful to know about you?
AGREEMENT/REMINDERS:

I understand that all information I entered in this form will be considered strictly confidential.

ANY 1:1 conversation between the coach & client is kept strictly confidentially.

"What I see here, what I hear, here, stays here."

The data gathered from this form will only be used as a basis for the type of coaching the client will need.

I understand that in order to be successful, it is vital to follow the plan agreed by both the life coach and the client.

I am dedicated to being committed over the next few months to give this program and myself the best effort.
How did you find out about our services?

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