Lets Get to know you!

New! Let's get to know you!

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.

Name *

Date of Birth: *

Phone number: *

Emergency Contact name *

Emergency contact Number:

Weight *

Last Fasting Blood Glucose

Height *

Last HA1c if you have it.

Do you have any health issues that you want to share and improve on?

Right now, how would you rank your overall eating / nutrition habits?

Out of all the changes you'd like to make, which ones feel the most important? (write 3) *

Have you tried anything in the past (or recently) to change your habits, your health, your eating, and / or your body? *

Yes

No

If so, what?

Which of those things worked well for you, and why? Even just a little bit, and even if you might not be doing them right now *

Which of those things didn’t work well for you, and why not? *

If you were to consider maybe making more 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? *

Why have those things blocked you? *

How do you spend your time?

In average, how many hours do you spend:

In paid employment?

At school, or studying?

With Friends/ Being Social

Taking care of others

Doing other unpaid work /Volunteering

Adding all these things up, how much time total do you spend doing these activities?

On a scale of 1-10, how do you feel about your schedule, use of time and overall busyness?

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:

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

How do you normally cope with stress? What are your tools?

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

How READY are you to change your behaviours and habits? *

What could get in your way?

How WILLING are you to change your behaviours and habits? *

What could get in your way?

How ABLE are you to change your behaviours and habits? *

What could get in your way?

What do you expect from me as your Coach? *

What are you prepared to do to work toward your goals? *

Disclaimer

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

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Lets Get to know you!

New! Let's get to know you!

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