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Client Intake and Screening Form



Welcome to Your Wellness Coaching Journey!

We know this form is in-depth, but rest assured that every question is designed to provide us with a full understanding of your unique needs, goals, and challenges. By taking the time to answer thoroughly, you're setting the stage for a successful coaching experience that is truly personalized to help you achieve lasting results. Your answers will guide us in tailoring a plan that supports your individual wellness journey, making every step of the process more effective and impactful. Thank you for your commitment!

Date
Month
Day
Year
Birthday
Month
Day
Year
Multi-line address
Status
Single
Married
Partnership
Divorced
Separated
Widowed

GOALS

If you don't know please put I don't know

If you don't know please put I don't know

If you don't know please put I don't know

If you don't know please put I don't know

Select all that apply

DIETARY HABITS AND CONDITIONS

Select all that apply

Select all that apply

How often do you eat out / order delivery?
Never
Every Meal
1x per day
4-6x per week
2-3x per week
1x per week
2-3x per month
1x per month
Rarely
How often do you eat refined / processed foods?
Never
Every Meal
1x per day
4-6x per week
2-3x per week
1x per week
2-3x per month
1x per month
Rarely

This would include foods like baked goods, chips, candy, ice cream, etc.

Do you prepare your own food?
Yes
No
Do you enjoy cooking?
Yes
No
Is eating organic products important to you?
Yes
No
I don't know

Do you eat on the run, at the table, in front of the TV? Is eating relaxing, stressful, enjoyable, an obligation? Any other details that will help us understand your relationship with eating and food.

How frequently do you use tobacco?
Daily
3-6x per week
1-2x per week
2-3x per month
<1x per month
Never
How frequently do you consume alcohol?
Daily
3-6x per week
1-2x per week
2-3x per month
<1x per month
Never
How frequently do you consume caffeine?
Daily
3-6x per week
1-2x per week
2-3x per month
<1x per month
Never
How frequently do you use drugs?
Daily
3-6x per week
1-2x per week
2-3x per month
<1x per month
Never
Are you open to lab testing to determine your nutritional biochemistry for optimal feedback?
Yes
No
I don't know

Movement, Stress, and Rest

Select all that apply

How many times a week do you do vigorous activity?
≤1
2
3
4
5
6+

Examples include running, jumping rope, heavy yard work, swimming laps at a fast pace. 

How many times a week do you do moderate activity?
≤1
2
3
4
5
6+

Examples include brisk walking, dancing, swimming at a moderate pace, playing doubles tennis. 

How many times a week do you do light activity?
≤1
2
3
4
5
6+

Examples include walking slowly, housework, leisurely strolling. 

How active is your job?
Sedentary
Light
Moderate
Active
Very Active
How stressful would you rate your job?
Not stressful
Somewhat stressful
Pretty stressful
Very stressful
How stressful would you rate your life?
Not stressful
Somewhat stressful
Pretty stressful
Very stressful

Select all that apply

How many hours of sleep do you typically average per night?
≤5
6
7
8
9+

Examples include walking slowly, housework, leisurely strolling. 

Select all that apply

Health History

Select all that apply

Have you experienced any eating disorders during adolescence or adulthood
Yes
No

Wellness & Lifestyle

How would you rate your stability / balance?
Poor
Average
Good
Very Good
How would you rate your stamina?
Poor
Average
Good
Very Good
How would you rate your strength?
Poor
Average
Good
Very Good
How would you rate your cognitive abilities?
Poor
Average
Good
Very Good
How would you rate your emotional regulation?
Poor
Average
Good
Very Good
How would you rate your connection to loved ones?
Poor
Average
Good
Very Good
How would you rate your connection to yourself?
Poor
Average
Good
Very Good
How would you rate your romantic connections?
Poor
Average
Good
Very Good
How would you rate your strive for personal development?
Poor
Average
Good
Very Good
How would you rate your work-life balance?
Poor
Average
Good
Very Good
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