Wellness Coaching Questionnaire

Health and Wellness Questionnaire
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Age*
years
Height*
cm
Weight*
lb
Current Weight*
What do you do for a living?
None (seated all day)Moderate (light activity such as walking)High (heavy labor, very active)
None1-2 days3 daysmore than 4 days
Do you have any medical conditions, injuries or take any medications?*
How many pounds would you like to lose/gain, or what is your health goal?*
What have you tried before and why did it not work for you?*
YesNo
BreakfastLunchDinner
YesNo
1-33-5over 5never
1 glass2-3 glassesat least 640zwhat's water?
TeaCoffeeSodaEnergy Drinks
Right when I wake upMid-dayAfter workOther
1 not ready2345678910 lets do this
Why?*
AccountabilityJust starting!I've hit a plateau & I need to change thatI don't know what to eat for my goalsOther
YesNo
YesNo
Do you prefer at home or gym workouts?*
How many days per week are you willing to commit to physical exercise?*
TextEmailOther
Always check with a doctor before embarking on any new exercise program or nutrition coaching. As always, please know that you will be assuming any coaching at your own risk.
Signature*

Clear
Date

MonthDayYear
Date
I am so excited that you have taken the first step in reaching out to me to help you with your health and fitness goals. Often times, taking the first step is the hardest one. Due to a steady stream of requests, if I feel like we will be a good fit for each other, I will reach back out to you with next steps within 24-48 hours.

Feel free to visit my website at www.rhoadstofitness.com or

join us on Facebook at www.facebook.com/rhoadstofitness

Be blessed!
Should be Empty:

Health and Wellness Questionnaire