Initial Assessment & Triage Questionnaire Initial Assessment & Triage Questionnaire Please enable JavaScript in your browser to complete this form.Name *FirstLastDateTell 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 BirthGenderStaying in touchPlease print clearly.EmailMobile PhoneHome PhoneHow do you prefer me to contact you?EmailPhoneSkype or other video chatTextOther (please specify):Emergency contact name:Emergency contact phone number: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 performancePlease 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?1Single Line Text2Single Line Text3Why?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 differentHave 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?1 (HORRIBLE)2345678910 (AWESOME)Why?Are you regularly active in sports and / or exercise?Yes or NoIf so, approximately how many hours per week?Fewer than 5 hours5-910-1415-1920 or moreWhat 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 hours5-910-1415-1920 or moreWhat other types of movement and / or activities do you do?What’s around you?Who lives with you? Check all that apply.Spouse or partner(s)Roommate(s)Child(ren)Pet(s)Other family (e.g. parent, grandparent, sibling, etc.)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.MeSpouse or partner(s)Roommate(s)Child(ren)Other familyWho does most of the cooking in your household? Check all that apply.MeSpouse or partner(s)Roommate(s)Child(ren)Other familyWho decides on most of the menus / meal types in your household? Check all that applyMeSpouse or partner(s)Roommate(s)Child(ren)Other familyRight now, how much do the people and things around you support health, fitness, and / or behavior change?1 (NOT AT ALL)2345678910 (COMPLETELY)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 NoRight now, do you have any specific health concerns, such as illnesses, pain, and / or injuries?Yes or NoRight now, are you taking any medications, either over-the-counter or prescription?Yes or NoOn a scale of 1-10, how would you rank your health right now?1 (WORST)2345678910 (AWESOME)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?1 (MY LIFE IS PANICKED AND INSANE)2345678910 (MY LIFE IS PERFECTLY CALM AND RELAXED)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?1 (STRESS)2345678910 (EXTREME STRESS)On average, how many hours per night do you sleep?4 or fewer hours5 hours6 hours7 hours8 hours9 hours10 or more hoursHow 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?1 (NOT AT ALL)2345678910 (COMPLETELY)How WILLING are you to change your behaviors and habits?1 (NOT AT ALL)2345678910 (COMPLETELY)How ABLE are you to change your behaviors and habits?1 (NOT AT ALL)2345678910 (COMPLETELY)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.WebsiteSubmit