Health Coach Intake Form

Information you will need

• HEALTH COACH ONLY: What's your name?
• CLIENT ONLY: What's your name?
• What's your date of birth
• What's your phone number?
• What's your email address?
• What’s the name of your emergency contact?
• What's your emergency contact's phone number?
• What's your preferred contact method?
• What do you expect to get out of health coaching?
• What do you expect from your health coach?
• What did you do in the past to deal with your habits, health, eating, or body?
• How would you like this experience to be different from past attempts at becoming healthier?
• What kinds of changes to these habits, health choices, and your body do you want to make?
• What is the biggest barrier to making these changes?
• How would you rate your eating and nutrition habits on a scale of 1 10?
• Why do you give your eating and nutrition habits this rating?
• How many hours do you contribute to structured exercise per week?
• How many hours do you do other types of physical activity?
• What's your current fitness program?
• Do you live with your spouse or partner?
• Do you live with roommates?
• Do you live with children?
• Do you live with pets?
• Do you live with other family?

…and 44 more fields in the PDF.

Completed by the client.

The form includes 1 signature line.