Willow Spring Health Coaching – Client Intake Form

Willow Spring Health Coaching – Client Intake Form
Personal Information
Name

First NameLast Name
Age
Email
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Main Health Goals
Describe the health and lifestyle transformation you want to achieve during our coaching relationship.
Describe the patterns you fall into again and again with regard to making health changes. What other diets, programs, or approaches have you tried in the past, and what were your results?
Describe your beliefs about your ability to transform your own health.
What support do you have at home, at work, and in your life to help you succeed?
What barriers do you perceive or predict? What has previously gotten in the way of your success?
What hobbies, interests, and passions do you have?
What is going to motivate you to keep going even when it gets uncomfortable?
Nutrition
Describe your current diet — a typical day of eating including breakfast, lunch, dinner, snacks, and beverages with times.
Which protein sources do you eat and how often?
What whole grains do you eat and how often?
What refined carbohydrate snacks (candies, crackers, cookies, pastries, baked goods) do you eat and how often?
What are your favorite foods?
Do you try to avoid any certain foods? If so, which ones?
What foods do you crave? How often do you give in to cravings?
Do you experience any symptoms or feelings if meals are missed? Please explain.
Are you currently taking any nutritional supplements? Please list all.
Beverages
Water — how many glasses/servings per day?
Coffee — how many servings per day/week? How do you take your coffee?
Tea — how many servings per day/week? How do you take your tea?
Fruit or vegetable juice / kombucha — servings and frequency. Please include type, when, and why.
Milk and non-dairy milk — servings and frequency. Please include type, when, and why.
Smoothies or shakes — servings and frequency. Please include ingredients, when, and why.
Soda and diet soda — servings and frequency.
Alcoholic beverages — servings and frequency. Please include type, when, and why.
Energy and Mood
Describe your energy levels throughout the day. Do you have highs and lows? When?
On a scale of 1–10, how would you rate your current stress level?
Describe your sources of stress.
How do you react to stress? Do you rely on any coping mechanisms?
Sleep
Sleep quality — check all that apply:
How many hours of sleep do you get most nights?
What time do you typically go to bed?

Hour Minutes

AM/PM Option
What time do you typically wake up?

Hour Minutes

AM/PM Option
What else should I know about your sleep habits, patterns, quantity, and quality?
Exercise and Movement
Describe your daily non-exercise movement (walking around, chores, manual tasks, etc.).
What do you do for exercise? Describe the types of activities, frequency, duration, and intensity.
Are you a competitive athlete?
If yes, describe your sport.
Fitness goals — check all that apply:
If you selected "Improved physical performance" or "Other," please describe your goals here. Also note any physical limitations that affect your ability to exercise.
Bowel Health
How often do you have a bowel movement?
Do you ever have difficult or unusual bowel movements? If so, please describe.
Work and Life
What do you do for work?
Do you usually enjoy your work?
How many hours a day do you typically work?
What type of schedule do you work? Check all that apply:
If you work a random schedule, briefly explain what that means.
Describe your family and home-life situation. (Married? Children? Caring for elderly parents? Share as much as you are comfortable with.)
Medical History
Have you been diagnosed with any diseases or conditions? Are you on any prescribed medications? Please describe.
Have you ever been hospitalized or had any major surgeries? Please describe.
Do you have any allergies or sensitivities?
If yes, please describe your allergies or sensitivities.
Do you smoke?
Do you use recreational drugs? If yes, which ones, how often, and why?
Please describe any pertinent family medical history.
Women's Health
Are you or could you be pregnant?
Are you pre-menopausal, perimenopausal, menopausal, or experiencing menopause symptoms? Please describe.
Additional Notes
Do you have any additional notes, comments, or questions?
Acknowledgement
I understand that the services provided are at all times restricted to consultation on the subject of health matters intended for general wellbeing and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being acknowledged voluntarily.
I acknowledge and agree to the above statement.
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Willow Spring Health Coaching – Client Intake Form

Personal Information

Main Health Goals

Nutrition

Beverages

Energy and Mood

Sleep

Exercise and Movement

Bowel Health

Work and Life

Medical History

Women's Health

Additional Notes

Acknowledgement