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
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?
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:

Rows	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?
How often are you willing to train weekly to reach your goal?
At what time during the day would you prefer to train?
Have you worked with a personal trainer before?
If yes, in your own words, please share what you enjoyed about that experience:
Have you received dietary assistance before?
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)?
If yes, what kind of training are you doing (i.e. strength, HIIT, yoga, pilates, etc.)? Please describe:
How long are your training sessions?
Your current diet could be best characterized as:
How many meals do you eat per day?
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).
Please rate your motivational level to commit to reaching your goals (1 = very low motivation, 5 = highly motivated).
Are you experiencing any stresses or motivational problems that would create any barriers?
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.Format: (000) 000-0000.
I would like to schedule a follow-up call on the date selected below:

MonthDayYear
Date
Should be Empty:

Goals & Vision