Client Intake Can’t wait to get to know you! New Client Intake Form Step 1 of 8 – Contact Info 12% Name(Required) First Last Date(Required) MM slash DD slash YYYY Email(Required) Phone(Required) Preferred Method of Contact(Required) phone (call / text) email In general, what do you want out of this experience? What are your goals? (check all that apply)(Required) lose weight improve physical fitness look better feel better have more energy improve overall health gain control over unhealthy eating habits gain a better understanding of nutrition gain a better understanding of holistic health manage stress other please specify: What do you want to change? How specifically would you like to change your habits? Your health? Your eating? Your lifestyle?(Required)Have you tried anything in the past (or recently) to change your habits? Your health? Your eating? Your lifestyle?(Required)Which of these things worked well for you, and why?(Required)Which of these things did not work for you and why not?(Required)When you think about changing your habits, what changes come to mind? What do you think would help you be successful in reaching your goals?(Required)What are some of the barriers you have faced in reaching your goals?(Required) How would you rate your current eating/nutrition habits?(Required) 1 – Horrible 2 3 – Okay 4 5 – Amazing What are your favorite foods/meals to eat? (list as many as you would like)(Required) Are you regularly active? (moving more than sitting)(Required) Yes No If so, what types of activities are you currently doing? (walking, exercising, gardening, being outside, playing with kids, housework/cleaning)(Required)What types of movement and or physical activities do you enjoy doing?(Required) Who lives with you? Check all that apply.(Required) Spouse/Partner Roommate(s) Child(ren) Pet(s) other family Who does most of the grocery shopping? Check all that apply.(Required) Me Spouse/Partner Roommate(s) Child(ren) Other family Who does most of the cooking in your household? Check all that apply.(Required) Me Spouse/Partner Roommate Child(ren) Other family Who decides the menu/meals for the week? Check all that apply.(Required) Me Spouse/Partner Roommate Child(ren) Other family How supported do you feel by the people around you?(Required) 1- not very supported 2 3 4 5- I have a wonderful support system What is your typical stress level on an average day?(Required) No stress Minimal stress Moderate stress High stress Very high stress How do you normally cope with stress?(Required) On average, how many hours of sleep do you get per night?(Required) 4 or less 5-6 hours 7-8 hours 9+ hours How many hours of sleep do you feel you need to feel your best?(Required) Have you been diagnosed with any medical conditions and or injuries? (currently or in the past)(Required)Do you currently have any specific health concerns, such as illnesses, pains or injuries?(Required)Do you currently take any medications, either over the counter or prescription? Please list all and tell how often you are taking them.(Required)Do you currently take any supplements, vitamins or medicinal herbs? Please list all and how often you are taking them.(Required) Are you READY to make changes to improve your health?(Required) No I think so Neutral Yes, I’m ready Are you WILLING to make changes to improve your health?(Required) No I think so Neutral Yes, I’m ready Are you ABLE to make changes to improve your health?(Required) No I think so Neutral Yes, I’m ready What are your expectations of me as your coach? What are you hoping to get out of health coaching?(Required) 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 Signature(Required)CAPTCHA