How do you prefer to be contacted *
In General, What are your goals? *
1= Awful / 10= Perfect
Have you tried anything in the past (or recently) to change your habits, your health, your eating, and / or your body? *
Are you regularly active in sports and / or exercise?
If so, how many hours per week?
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)
Who lives with you?
Who does most of the grocery shopping in your household?
Who does most of the Cooking in your household?
Who decides on most of the menus / meal types in your household? Check all that apply.
1= not at all

How do you spend your time?

In average, how many hours do you spend:

1= Relaxed 10= insane

How is your Stress and recovery?

Think about all the activities you're involved in (ex: work, school, care giving, housework, travel) Then asses the best you can:

1 = Calm 10= Extreme stress
On average, how many hours per night do you sleep? *

How ready, willing, and able are you to change?


Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking health coaching.

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