Client Background
Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred Method of Contact
Phone call
Text
EMail
Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.
Health & Medical Background
Month/Year of Diagnosis
Type/Stage
Treatment(s) completed (surgery, chemotherapy, radiation, hormone therapy, targeted therapy, reconstruction, etc.)
When did you finish treatment?
Current Medical Status
Any other relevant information
Current Medications & Supplements
Prescription medications (dosage + frequency)
OTC medications/vitamins/supplements
Other therapies (e.g., hormone replacement, alternative/complementary treatments
Lifestyle
Current physical activity level (types of exercise, frequency, limitations)
Sleep Quality (1: poor, 10: great)
Typical diet and eating habits (Please be as honest as possible, no judgements here)
Stress levels & coping strategies
Alcohol, caffeine, tobacco use
Symptoms, Challenges & Concerns
Current side effects or lingering symptoms (e.g., fatigue, lymphedema, joint pain, brain fog, digestive issues, mood changes)
Emotional/mental health concerns (e.g., anxiety, fear of recurrence, body image)
Any restrictions from your medical team?
Support System & Resources
Primary care physician/oncologist contact (optional)
Do you current work with therapists, coaches, or support groups?
Do you have Family/friends involved in your healing journey?
Goals & Intentions
What motivated you to seek health coaching at this time?
Have you worked with a Health Coach in the past? What was your experience?
What are your top 3 goals for your health and well-being right now?
What does “feeling well” look like to you?
Are there specific areas you’d like the most support with? (nutrition, movement, mindset, stress, energy, body confidence, long-term prevention, etc.)
Consent & Acknowledgements
Check to acknowledge
Agreement that coaching is not medical advice or a substitute for medical care. Permission to contact your healthcare provider, if necessary, per your authorization.
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