HMW Coaching Questionnaire

Hot Mom Wellness Questionnaire

Welcome, mama! I’m so excited you’re here. Please take 5–7 minutes to answer the questions below honestly and thoroughly. This will help me understand where you are in your journey and how I can best support you through personalized wellness coaching.
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age
years
Height
in or cm
Weight
LB or KG
What stage of motherhood are you currently in? (Select all that apply)

Trying to conceiveCurrently pregnant — Trimester: ___Postpartum (0–3 months)Postpartum (3–12 months)1–5 years postpartumOther
Was your pregnancy vaginal, cesarean, or other? Any complications?
Are you currently breastfeeding or chestfeeding?

YesNoWeaning
Do you have any diagnosed health conditions or concerns I should know about? (e.g. PCOS, thyroid imbalance, anemia, depression, pelvic floor dysfunction, etc.)
Are you currently on any medications or supplements?
Do you have clearance from your provider to participate in light physical movement or fitness coaching?
What are your biggest struggles right now?(Check all that apply and feel free to elaborate)

Low energy / fatigueHormonal imbalanceBody image / confidencePelvic floor weakness or painInconsistent nutritionMood swings or emotional lowsNot feeling “like myself” anymoreLack of motivation or routineStress / anxietyOther
How would you describe your relationship with your body today?
What are 3 goals you hope to achieve from this coaching experience?(Physical, mental, emotional or lifestyle)
Have you worked with a coach before? If so, what worked or didn’t?
How committed are you to investing in your health and wellness at this time?

Just curiousReady but cautiousFully ready to prioritize meI’ve been waiting for something like thisOther
Please rate your readiness for change.

12345678910
Are you willing to financially commit to changing your life?*

YesNo
How do you prefer to be contacted?

CallTextEmail
Appointment
Anything else you'd like me to know before we talk?
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! You've just scheduled your 15 minute discovery call with me so we'll be in touch soon!
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Hot Mom Wellness Questionnaire