Initial Assessment and Triage

Initial Assessment and Triage

Your Name *

Today's date *

 

Tell me more about yourself.

By learning more about your lifestyle and habits, I can take better care of you and make sure that coaching is a good fit for your individual goals and needs.

Date of Birth *

Gender *

 

Staying in touch.

Your Email *

Your Phone *

How do you prefer me to contact you?
EmailTextPhone callSkype or other video chatOther

How often would you like me to contact you? *

 

What do you want?

In general, what are your goals? Check all that apply. *
lose weight / fatgain weightMaintain weightAdd muscleImprove physical fitnessLook betterFeel betterHave more energy and vitalityGet control of eating habitsGet strongerPhysique competition/modelingImprove athletic performance

Please list all of your concerns about your health, eating habits, fitness, and/or body *

Out of all the above concerns, which ones feel the most important/urgent? *

Why? *

 

What do you expect?

What do you expect from me as your coach? *

What are you prepared to do to work towards your goals? *

 

What do you want to change?

Have you tried anything in the past to change your habits, your health, your eating, and/or your body?
YesNo

If so, what?

Which of those things worked well for you? (Even if you might not be doing it right now.) *

Which of those things didn't work well for you? *

How, specifically, would you like your habits, your health, your eating, and / or / your body to be different? *

Have you already made changes to your habits, your health, your eating, and / or your body recently?
YesNo

If so, what?

If you were to consider making further changes to your habits, your health, your eating, and / or your body, what might those be? *

Until now, what has blocked you or held you back from changing these things? *

Right now, how would you rank your overall eating / nutrition habits? (1 being horrible, 10 being awesome!!!)*

Why?

How many hours per week do you engage in active sports and / or exercise?
Fewer than 5 hours5 to 910 to 1415 to 1920 or more

What types of sports and / or exercise do you typically do? *

Approximately how many hours a week do you do other types of physical activity? (e.g., housework, walking to work or school, home repairs, moving around at work, gardening
Fewer than 5 hours5 to 910 to 1415 to 1920 or more

What other types of movement and / or activies do you do? *

 

What's around you?

Who lives with you? Check all that apply. *
Spouse or partner(s)Roomate(s)Child(ren)Pet(s)Other family (e.g. parent, grandparent, sibling, etc.)

Do you have children?
YesNo

If so, How many and what are their ages?

Who does most of the grocery shopping in your household? Check all that apply. *
MeSpouse or partner(s)Roomate(s)Child(ren)Other family

Who does most of the cooking in your household? Check all that apply. *
MeSpouse or partner(s)Roomate(s)Child(ren)Other family

Who decides on most of the menu/meal types in your household? Check all that apply. *
MeSpouse or partner(s)Roomate(s)Child(ren)Other family

Right now, how much do the people and things around you support health, fitness, and/or behavior change? (1 being not at all, 10 being completely!!!)*

 

What's your health like?

Have you been diagnosed (currently or in the past with any significant medical condition(s) and / or injuries?
YesNo

Right now do you have any specific health concerns such as illnesses, pain, and / or injuries?
YesNo

Right now, are you taking any medications, either over the counter or prescription?
YesNo

Do you have any allergies? If so, what are they?

On a scale of 1 to 10, how would you rank your health right now? (1 being worst, 10 being awesome!!!) *

Why?

 

How are you spending your time?

In an average week, how many hours do you spend...

In paid employment? *

Taking care of others? (e.g., children, person with a disability, older person) *

At school or doing school work? *

Doing other unpaid work? (e.g., housework, errands) *

Traveling and / or commuting? *

Volunteering? *

Adding up all these things, how many total hours per week do you spend doing all these activities? *

On a scale of 1 to 10, how would you feel about your schedule, time use, and overall busy-ness? (1 being my life is panicked and insane, 10 being My life is perfectly calm and relaxed) *

 

How is your stress and recovery?

Given all the demands of your life, what is your typical stress level on an average day (1 being no stress, 10 being extreme stress) *

On average, how many hours per night do you sleep *

How do you normally cope with your stress?

 

How ready, willing, and able are you to change?

Right now, on a scale of 1 - 10: (1 being not at all, 10 being completely)

How READY are you to change your behaviours and habits? *

How WILLING are you to change your behaviours and habits? *

How ABLE are you to change your behaviours and habits? *

 

Disclaimer

Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and / or fitness consultation.

Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.

 

I have read the disclaimer and agree to accept full responsibility.

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