4Wellness Coaching Intake
Welcome! I’m so glad you’re here 🤍 This is a judgment-free space. Please answer honestly and as thorough as possible so I can best support you in your health journey—physically, mentally, and spiritually.
Full Name
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First Name
Last Name
Email Address
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
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-
Month
-
Day
Year
Date
Occupation (sedentary/desk job, physically active/manual labor, or a hybrid roles)
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Spiritual Background
Do you have a personal relationship with Jesus Christ?
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Yes
No
I want to!
Are you currently involved in a church community?
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Yes, regularly
Occasionally
No
Please describe your current faith practices (prayer, study, worship, etc.)
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How important is your faith in your health journey?
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In what ways would you like to invite God into your wellness journey?
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Health & Nutrition
Please list all your concerns about your health, eating habits, fitness and/or body
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Out of all of the above concerns, which ones feel most important/urgent? Why?
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How would you describe your current nutrition habits?
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What do you typically eat for breakfast? Be as detailed as possible
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What do you typically eat for lunch? Be as detailed as possible
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What do you typically eat for dinner? Be as detailed as possible
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What do you typically eat for snacks? Be as detailed as possible
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Do you currently follow any of the following diets, check all that apply.
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No
Gluten-Free
Dairy-Free
Low Carb
Paleo
Whole 30
Sugar-Free
Vegan
Mediterranean
Plant Based
Vegetarian
Intermittent fasting
Keto
See-Food Diet (I see food, I eat it)
Cardiac Diet
Liquid Diet
Other
What are your biggest struggles with nutrition right now?
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Over eating
Binge Eating
Cravings
Emotional eating
Boredom eating
Lack if time
Not knowing what to eat
Consistency
Lack of financial resources for healthy food
Other
Explain any checked boxes above
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How would you describe your relationship with food?
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Right now, how would you rank your overall eating/nutrition habits?
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Horrible
1
2
3
4
5
6
7
8
9
Awesome
10
1 is Horrible, 10 is Awesome
Why do you give yourself that ranking?
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Do you have any food allergies or sensitivities?
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How would you describe your current energy levels
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Low
Up and down
Good
High
Other
Do you feel like your eating is ever connected to your emotions? Please explain
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What tends to throw you off track the most?
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Do you struggle with the weekends with your eating habits? If so, please explain.
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What foods will you NOT eat?
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What foods do you love to eat?
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If we were 3 months from now, what would success look like for you?
Are you regularly active in sports and/or exercise?
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Yes
No
If yes, approximately how many hours per week?
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1-2
3-5
6-10
12+
What types of sports/ and or exercise do you typically do?
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What other types of movement and/or activities do you do on a regular basis
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Who lives with you? Including children.
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On average, how many meals do you eat outside of the home? Ie. non-home cooked meals, going out to eat, drive thru meals etc.
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Who does most of the grocery shopping in your household?
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Me
Spouse
Roommate
Other
Who does most of the cooking in your household?
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Me
Spouse
Roommate
Child(ren)
Other
Who decides on most of the menus/meal types in your household?
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Me
Spouse
Roommate
Child(ren)
Other
Right now, how much do the people in your household and around you support your health, fitness, and/or behavior changes?
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Not at all
1
2
3
4
5
6
7
8
9
Completely
10
1 is Not at all, 10 is Completely
Wellness Goals
What are your main health and wellness goals?
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Overall health
Lose weight/fat
Maintain Weight
Improve physical health
Look better
Feel better
Have more energy
Get control of eating habits
What made you decide to seek coaching?
What are your top spiritual wellness goals?
Health History & Medications
Have you been diagnosed (currently or in the past) with any significant medical conditions or injuries?
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Right now, do you have any specific health concerns, such as illnesses, pain, and or injuries?
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Please list any relevant medical history.
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Are you currently taking any medications? If yes, please list them.
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Are you currently taking any supplements? If yes, please list them.
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Do you have any GI symptoms? (stomach)
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Do you have chronic headaches/mirgaines?
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Are you currently pregnant or nursing?
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Have you started perimenopause or are you in menopause?
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Allergies & Dietary Restrictions
Do you have any allergies or dietary restrictions?
Daily Schedule & Meal Pattern
Briefly describe your typical daily schedule.
Describe your usual meal pattern (number of meals/snacks, meal times, etc.).
Stress and Sleep
How would you rate your stress level?
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Low
Moderate
High
How do you handle stress?
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Explain what in your life is stressful.
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On average, how many hours of sleep do you get per night?
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4 or fewer hours
5 hours
6 hours
7 hours
8 hours
9 hours
10+
Do you feel rested after sleeping 7 + hours?
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Yes
No
I am always full of energy
I am always exhausted
Readiness & Commitment
How ready are you to make a change with your nutrition and eating habits?
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Not ready
1
2
3
4
5
6
7
8
9
100% Ready
10
1 is Not ready, 10 is 100% Ready
How WILLING are you to change your behaviors and habits?
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Not willing
1
2
3
4
5
6
7
8
9
100% willing
10
1 is Not willing, 10 is 100% willing
Why do you feel like NOW is the time to make a change?
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What has held you back in the past?
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Consent & Coaching Policies
How did you hear about Kelsey Miranda or 4Wellness?
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Please Select
Referral from friend/family
Church or faith community
Social media
Online search
Event or workshop
Other
Disclaimer
Agreement & ConsentBy signing below, you acknowledge that you are voluntarily participating in 4Wellness Nutrition Coaching services. You understand this program is not medical nutrition therapy and does not replace professional medical advice.You agree to assume full responsibility for your health, choices, and actions, and release Kelsey Miranda and 4Wellness from any liability related to your participation.
Signature
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What happens next: Once you submit this form, I’ll personally review your answers and reach out within 24–48 hours with next steps 🤍. If your submission falls on a weekend or holiday, please allow a little extra time for my response—I will get back to you as soon as possible! I am already praying over the women stepping into this journey and I am honored that you have trusted me to guide you on your 4Wellness journey through Word, Worship, Witness, Workout/Nutrition. God bless!
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