Wondering if Wellness Coaching is right for you? Complete this questionnaire as much as you can so that together we can figure out the right path for you!By doing so you will also be subscribing to our wellness newsletter. Name * First Name Last Name Email * Phone Number Country (###) ### #### GENERAL HEALTH: Please list your main health concerns and include any serious illnesses affecting your health and any medications you are taking. Any serious hospitalizations/injuries/setbacks in the past 5 years? At what point in your life did you feel best? What about that time (habits, emotions, activity, etc) would you like to reconnect with and incorporate into your daily well-being? GENERAL NUTRITION: How would you rate your nutrition? Is your Nutrition excellent? where Strongly Disagree means you have Poor nutrition and Strongly Agree means you have Excellent Nutrition Strongly Disagree Disagree Neutral Agree Strongly Agree Please select the reasons you eat (besides hunger). Stress Depression Boredom Happiness Habit Annoyance Other if you have checked "other" in the previous question, please state the other reasons below: What percentage of your food is home-cooked? Are you interested in cooking at home more? Yes No PHYSICAL ACTIVITY: How often do you exercise per week currently? What types of exercise do you do on a regular basis? Have you had any injuries or surgery that require specialized training and rehabilitation? Aside from injuries or surgery, do you experience any additional restrictions to your mobility? If so please describe in detail and include any treatment you are currently receiving. What’s one activity you want to be able to do in one month’s time? What’s one activity you want to be able to do in six month’s time? PATH TO SUCCESS: What do you feel good about in your life right now? What is your vision for yourself? How do you see yourself in a year and how would you like to feel? What changes would you like to make to achieve your vision? How would you describe your health journey up to this point? Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? Yes No Are you interested in a shorter term goal or a longer term transformation? Shorter Term Goal Long Term Transformation If you chose "long term transformation," describe your long-term goals in detail including the positive outcomes you desire as a result of health coaching? (Some examples include: weight loss, diminished cravings, better sleep, more energy, reduced pain and inflammation, enhanced mood, reduced brain fog, improved athletic performance, etc.) What do you hope for in a coaching relationship? Where do you feel you need the most support and accountability? What is motivating you to pursue health coaching? What is your WHY? This is a very important step so please dig deep on this one because your overall success will depend on it! Does this motivation differ from what you’ve felt in past attempts to change your health? Do you perceive any barriers to your desires to make a change? How ready are you to make changes? Very Ready Somewhat Ready Not Ready Thank you for your submission, we will review the information you have provided and will contact you shortly. In the meantime if you have any questions, please feel free to contact us by email at trish@stokedbodies.com or by calling us at 858-422-1975. Have a wonderful day!
