Client Intake
DATE
/
Month
/
Day
Year
Date
Name
*
First Name
Last Name
Gender
Age
*
Height
Current Weight
Email
*
example@example.com
Phone
*
Format: (000) 000-0000.
Emergency contact name
*
Emergency contact phone number:
*
Format: (000) 000-0000.
Marital Status
*
Single
Engaged
Married
Divorced
Widowed
If you have children, how many and what are their ages?
Who lives with you? Check all that apply.
*
Spouse
Child(ren)
Other family (ex. parent, grandparent, sibling, etc.)
Roommate(s)
Pet(s)
Other
What is your current occupation? Are you full-time, part-time, per diem?
*
Right now, how much do the people and things around you support your sleep, health, and behavior change?
*
Not at all
Some
Mostly
A lot of support
In general, what are your goals? Check all that apply.
*
Sleep better
Improve overall health
Have more energy and vitality
Feel better
Get control of eating habits
Gain mental clarity
Have more emotional control
Manage stress better
Rest better
Make better food choices
More confidence in making choices that have positive impact on health
More balanced life
Feel more at peace
Other (please specify)
Out of all of the changes you’d like to make, which ones feel most important / urgent and why?
*
Have you been diagnosed (currently or in the past) with any significant medical condition(s) I should be aware of? If so, please list.
*
Right now, are you taking any medications or supplements? If so please list.
*
On average, how many hours per night do you sleep?
*
4 or fewer hours
5-6 hours
7 hours
8 hours
9 hours
10 or more hours
What is your typical bedtime?
On a scale of 1-10, how good is your sleep quality?
1 - HORRIBLE
2
3
4
5
6
7
8
9
10 - AWESOME!
Do you have trouble falling asleep, staying asleep, or both? If you wake up in the night do you have trouble getting back to sleep?
Why do you think sleep has been difficult for you? What tends to interfere with you getting enough sleep, and / or the quality of your sleep?
What, if anything, tends to help you sleep better / longer?
What things have you tried that didn't work?
Do you currently take anything to help you sleep? (Rx or OTC medications, herbal supplements, alcohol, etc), if yes please list.
How long have you been having sleep struggles?
I worry about not getting enough sleep.
Never
Rarely
Occassionally
Most nights/days
Always
I try to "catch up on sleep" on weekends or other times.
Never
Rarely
Occassionally
Most nights/days
Always
I find it hard to wake up or get going after I wake up.
Never
Rarely
Occassionally
Most nights/days
Always
I wake up with an alarm.
Never
Rarely
Occassionally
Most nights/days
Always
I hit snooze on the alarm once or more.
Never
Rarely
Occassionally
Most nights/days
Always
I feel moody, cranky, "down in the dumps", and/or blah.
Never
Rarely
Occassionally
Most nights/days
Always
I struggle to concentrate, learn, and/or remember things.
Never
Rarely
Occassionally
Most nights/days
Always
Left to my own devices, without having to accommodate someone else's schedule, I'd consider myself:
An early bird
A night owl
A mix, depends on the day
Which of these statements have you thought/said or agree with? Check all that apply.
I will never fall asleep
I woke up in the middle of the night or early morning and feel wide awake. This means I will not be able to fall back to sleep.
I must get eight hours of sleep
My insomnia will cause health problems
I can’t fall asleep without a sleeping pill or aid
I feel awful today because I didn’t sleep well.
I’m just a bad sleeper or I will never learn to sleep better.
What is wrong with me? I must have a mental health or hormone problem
After a poor night’s sleep, I know it will interfere with my activities the next day and I will have a hard time functioning
When I sleep poorly one night, I know it will disturb my sleep schedule for the whole week.
Without an adequate night’s sleep, I can hardly function the next day.
I can’t ever predict whether I’ll have a good or poor night’s sleep
Is this just my life now
Many things can cause us stress. Check all that you’ve experienced in the last six months.
Death of partner; close family; or friend
Ongoing pressure and demands at work or school
Caring for child(ren)
Death of someone else you cared about
Caring for sick, disabled, and / or older family member or friend
Death of pet
Recently retired
Child left home
You left home
Debt, lost money, or other financial pressures
Moved house
Other change to family situation
Moved to a new region
Significant or frequent travel
Fast-paced / busy / rushed life
Major physical health problem
Started school
Got married
Graduated from school
Ongoing relationship problems
Substance abuse issues and / or another addiction
Started a new job / career
Changed jobs
Relationship breakup / divorce or separation
Heavy athletic training or other physical endeavors
Long work hours (10+ hours/day)
Shift work
Ongoing problems with other family, relatives, friends
Athletic competition
Occupational exposure to toxins
Pregnancy / new baby
Other
Do you have history of trauma?
Yes
No
Given all the demands of your life, what is your typical stress level on an average day?
*
1 - No Stress
2
3
4
5
6
7
8
9
10 - Extreme Stress
How would you rate your ability to handle stress?
*
1 - It's a struggle
2
3
4
5
6
7
8
9
10 - I'm bulletproof
On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?
*
1- My life is perfectly calm and relaxed
2
3
4
5
6
7
8
9
10- My life is panicked and insane
On a scale of 1-10, how would you rate your ability to rest in the midst of your regular day to day demands?
*
1- I can't rest until I'm caught up or things slow down
2
3
4
5
6
7
8
9
10- I know how to recover and am capable of incorporating sustaining periods of rest in my day even amid demands
What, if anything, do you do right now to cope and / or recover from stressors?
How mentally “sharp”, quick, and clear do you normally feel on an average day?
1 - Total brain fog
2
3
4
5
6
7
8
9
10 - Genius
How many times do you exercise per week? (list typical activities)
Right now, how would you rank your overall eating / nutrition habits?
*
1 - HORRIBLE
2
3
4
5
6
7
8
9
10 - AWESOME
How many caffeinated beverages do you consume per day?
How many alcoholic beverages do you consume per week?
How many times do you eat out per week?
List the 3 worst foods you eat during the average week:
List the 3 healthiest foods you eat during the average week:
For women: If you should be having regular periods, are you?
YES
NO
If no, how long has it been since your last period? Note if due to menopause, pregnancy/postpartum, or breastfeeding, etc
Do you attend church regularly?
*
On a scale of 1-10 how would you rate your spiritual health? (1= faint hearted, 10= fearless faith)
*
Imagine you are nearing the end of your life. When you look back, what are the accomplishments or events that brought meaning to your life? What gives you a sense of purpose? What activities have meaning and make your life satisfying and fulfilling?
*
What would you like your legacy to be?
*
What gives you a sense of purpose in life? What activities have meaning for you?
*
What brings you a sense of happiness and joy?
*
What are your hobbies?
Is there anything else I should know about your personal life, struggles, worries, etc?
What do you expect from me as your coach?
How did you hear about me?
Disclaimer
Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking health and wellness consultation. Any information provided is not to be followed without prior approval from 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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