LET'S GET STARTED Wellness Consultation Questionnaire Step 1 of 6 - General Information 16% Name* First Last Date of Birth* DD slash MM slash YYYY Gender* Male Female Ask Me Other Do you have private health insurance with any of the following funds: BUPA, WESTFUND or RT HEALTH?* Yes No How Did You Hear About Me?* Occupation* Height* Current Body Weight* Ideal Body Weight In your current roles (in business and in life), how many people a day would you say you support/lead/cheer on/lift up?* 0 1-5 6-10 11-20 21-100 100+ How do you fill your own cup (self-care/health/wellness)?Daily Activity* Sedentary - Sitting at the computer most of the day, or sitting at a desk Lightly active - Light industrial work, sales or office work that comprises light activities Moderately active - On your feet comprised of moderate activity (ex: Cleaning, kitchen staff, or delivering mail on foot or by bicycle.) Very active - Heavy industrial work (iron, coal, etc.), construction work, brick mason, or farming Workout Activity* Sedentary - No working out Lightly active - Low intensity aerobics Moderately active - High intensity aerobics or weight training Very active - Weights 3+/week + aerobics Extremely active - 2+ hrs/day and athletes Primary Email (This is used to confirm appointments and send reminders so please use an email you check frequently)* Mobile Number* How do you prefer me to contact you? Phone Email App If none of the above options suits you, please write here how do you prefer me to contact you. If you use Facebook, what is your Facebook name (so we can connect on social media)? Lose weight/fat Gain weight Maintain weight Add muscle Improve physical fitness Look better Feel better Have more energy/vitality Get control of eating habits Get stronger Other In general, what are your goals? Write down ALL the goals from above that apply.*Please list all of your concerns about your health, eating habits, fitness and/or body*Out of those concerns listed above, which one(s) feel most important or urgent?*What makes it/them important/urgent to you?*Current Photo[Optional] Do you have a current picture of yourself that you’d like to upload so I can see where you are starting? Skip to the next question if you do not have one.Accepted file types: jpg, png, pdf, Max. file size: 2 MB.Goal PhotoPlease upload a photo of a physique that looks similar to what you’d like to achieve. (Does not have to be a photo of you).Accepted file types: jpg, png, pdf, Max. file size: 2 MB. What do you expect from me as your healthy habit coach?*Have you tried anything in the past to change your habits, your health, your eating and/or your body? If so, what?Which of those things worked well for you? (Even if you might not be doing them now)Which of those things did NOT work well for you?If you could improve your health in 3 ways, what would they be?* Have you been diagnosed (currently or in the past) with any significant medical condition and/or injuries?* Yes No If yes, please list.*Right now, do you have any specific health concerns such as illnesses, pain, and/or injuries?* Yes No If yes, please list.*Are you currently taking any prescription or over the counter medicines?* Yes No If yes, please list dosage, strength and frequency.*Do you suffer from: Allergies Asthma Heart disease Or any other condition that can be aggravated by heat and humidity? On a scale of 1-10, how do you rank your health right now? (where 1=Horrible and 10=Awesome)*10987654321Why?*How would you rate your energy levels?*10987654321What's your current ENERGY health goal?*What do you typically have for breakfast?*What do you typically have for lunch?*What do you typically have for dinner?*If you have snacks, what are they?What are your vices? Choose one of the options* Select All Chocolate Chips/crisps Alcohol Fast food/Takeaway Sugary beverages Caffeine Other Do you drink coffee? If so, how do you have it? How much do you typically spend on breakfast, lunch, coffees/soft drinks & vices DAILY?* $1-$5 $5-$10 $10-$15 $15-$20 $20 + On a scale of 1-10, how would you rate your stress levels? (where 1=Chilled and 10=Very Stressed)*10987654321How many restful hours you sleep night?* Less than 4 hours 4-6 hours 6-8 hours 8-9 hours More than 9 hours What time do you usually wake up?* What time do you usually go to bed?* Last Question!How committed are you to yourself and change?*10987654321Healthy habit coaching is not intended to diagnose, treat, prevent or cure any disease or condition. It should not be a substitute for the advice, treatment and/or diagnosis of a qualified licensed professional. Certified health coaches may not make any medical diagnosis, claims, or substitute for your personal health practitioner's care. As your coach, I do not provide a second opinion or in any way attempt to alter the treatment plans or therapeutic goals of your personal physician or healthcare team. It is my role to partner with you to provide ongoing support, resources and accountability as you create an action plan to meet and maintain your health goals.
