Initial Assessment & Triage Questionnaire – Annie Berryhill- Healthy Lifestyle Strategist & Coach

Name *

First

Last

Date

Tell me more about yourself.

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

Date of Birth

Gender

Staying in touch

Please print clearly.

Email

Mobile Phone

Home Phone

How do you prefer me to contact you?

Email
Phone
Skype or other video chat
Text

Other (please specify):

Emergency contact name:

Emergency contact phone number:

What do you want? In general, what are your goals? Check all that apply.

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

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

1

Single Line Text

2

Single Line Text

3

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? 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? 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?

Why?

Are you regularly active in sports and / or exercise?

Yes or No

If so, approximately how many hours per week?

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)

What other types of movement and / or activities do you do?

What’s around you?

Who lives with you? Check all that apply.

Do you have children? If yes, how many and what are their ages?

Who does most of the grocery shopping in your household? Check all that apply.

Who does most of the cooking in your household? Check all that apply.

Who decides on most of the menus / meal types in your household? Check all that apply

Right now, how much do the people and things around you support health, fitness, and / or behavior change?

What’s your health like?

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

Yes or No

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

Yes or No

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

Yes or No

On a scale of 1-10, how would you rank your health right now?

Why?

How are you spending your time?

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 1-10, how do you feel about your schedule, time use, and overall busy-ness?

How is your stress and recovery?

Think about all the activities you’re involved in (e.g., work, school, caregiving, housework, travel). Then assess as best you can:

Given all the demands of your life, what is your typical stress level on an average day?

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?

How READY are you to change your behaviors and habits?

How WILLING are you to change your behaviors and habits?

How ABLE are you to change your behaviors 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.