Wellness Coaching Intake Questionnaire

Wellness Coaching Intake Questionnaire

Please complete the below questionnaire. Completion time: 5 minutes
To the best of my knowledge and belief, all the information I have given is correct. I confirm I have sought and followed any required medical advice and acknowledge that this information will be treated as confidential.
Full Name*

First NameLast Name
Gender*

MaleFemaleNon-BinaryTransgender
Date of Birth*

MonthDayYear
Age*
years
Height*
ft/inches
Weight*
lbs
What do you do for a living?*
Goals & Vision
Which of the following best describes your wellness goals?*

Improved overall healthImproved enduranceImproved flexibilityIncreased strengthIncreased muscle massFat loss
In your own words, please describe your wellness vision (i.e. where would you like to be 1-year from now):*

Timeline for achieving your goals and vision:*

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
Select one:

Needs Assessment
What types of services would you like to receive?*

In-Person Training Program (customized)Virtual Training Program (customized)Customized Dietary PlanBehavior Change and Habit Coaching
How often are you willing to train weekly to reach your goal?*
At what time during the day would you prefer to train?*

MorningMid-DayAfternoonEvening
Have you worked with a personal trainer before?*

YesNo
If yes, in your own words, please share what you enjoyed about that experience:*
Have you received dietary assistance before?*

YesNo
If yes, in your words, please share what you enjoyed about that experience:*
Habits Assessment
Are you currently training regularly (at least 3x per week)?*

YesNo
If yes, what kind of training are you doing (i.e. strength, HIIT, yoga, pilates, etc.)? Please describe:*
How long are your training sessions?*

30 minutes or less30-45 minutes45-60 minutes60-90 minutes90+ minutes
Your current diet could be best characterized as:*

Low-fatLow-carbHigh-proteinPescatarian (seafood only)Vegetarian/Vegan (no meat or diary products)No special diet
How many meals do you eat per day?

1-2 meals2-3 meals3-5 meals
Readiness Assessment
Please rate your readiness for change (1 = only thinking about it, 3 = planning and almost ready to commit, 5 = committed and ready to start).*

12345
Please rate your motivational level to commit to reaching your goals (1 = very low motivation, 5 = highly motivated).*

12345
Are you experiencing any stresses or motivational problems that would create any barriers?*

YesNo
If yes, please share what you're comfortable with disclosing:*
In your own words, please share how I could assist you as your coach and trainer:*
I Would Like to Move Forward to Next Steps
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
I would like to schedule a follow-up call on the date selected below:*

MonthDayYear
Date
Should be Empty:

Wellness Coaching Intake Questionnaire

Goals & Vision

Needs Assessment

Habits Assessment

Readiness Assessment

I Would Like to Move Forward to Next Steps