Assessment Form

Thank you for taking our assessment. Your answers to these questions will provide valuable insights into your lifestyle, habits, and aspirations, allowing us to create a personalized plan that aligns with your unique needs and goals. Let’s embark on this journey towards better health and well-being together!

Name

First

Last

What motivated you to seek the guidance of a health coach at this time?

How would you rate your current level of overall health and well-being on a scale of 1 to 10?

Selected Value: 1

Are there any specific health concerns or conditions you're currently managing or have dealt with in the past?

What does a typical day of eating look like for you? Do you have any dietary restrictions or preferences?

How do you feel about your current stress levels, and what strategies do you use to manage stress?

On average, how many hours of sleep do you get per night? Do you feel well-rested when you wake up?

Describe your current level of physical activity and exercise routine, if any. What types of activities do you enjoy?

How would you describe your relationship with food? Do you often eat in response to emotions or external triggers?

Are there any habits or behaviors you'd like to change or improve upon to enhance your overall health and well-being?

What specific goals do you hope to achieve with the support of a health coach? Are there any short-term or long-term objectives you have in mind?

Living more abundantly in mind body and spirit!

Assessment Form