Initial Assessment & Triage Questionnaire Source: PN worksheetPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastTell me more about yourselfBy 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. Add information about your current lifestyle and concerns and the direction you’d like to move towards and why!Email * Have and are Date of Birth *Enter date, month and year. We need this information for your age and metabolic health calculation Gender *PhoneHeight *Enter feet followed a period followed by inches. For example, if you are 5 feet 5 inches enter “5.5”.Weight *Enter weight in lbs rounded to the nearest whole number. For example, 170.4lbs will be 170lbs and 182.6lbs will be 183lbs.In general, what are your goals? Check all that apply. *Lose weight / fatGain weightMaintain weightAdd muscleImprove overall healthImprove physical fitnessLook betterFeel betterHave more energy and vitalityHealthy agingGet control of eating habitsGet strongerImprove athletic performanceOtherWhat do you want to change? *How, specifically, would you like your habits, your health, your eating, and / or your body to be different?Out of all of the changes you’d like to make, which ones feel most important / urgent? *List the top 1-3Have you tried anything in the past (or recently) to change your habits, your health, your eating, and / or your body? *YesNoIf so, what?Skip if you answered “no”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.)Skip if you answered “no” Which of those things didn’t work well for you, and why not?Skip if you answered “no”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?What are you doing right now? Selected Value: 1 Right now, how would you rank your overall eating / nutrition habits? 1 – Horrible, 10 – AwesomeAre you regularly active in sports and / or exercise? If so, approximately how many hours per week? *Not active at allFewer than 5 hours5-910-1415-1920 or moreWhat types of sports and / or exercise do you typically do?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) *Fewer than 5 hours5-910-1415-1920 or moreWhat other types of movement and / or activities do you do?Who lives with you? Check all that apply.Spouse or partner(s)Roommate(s)Child(red)Pet(s)Other family (e.g. parent, grandparent, sibling, etc.)Do you have children? If yes, how many and what are their ages? *Who does most of the grocery shopping in your household? MeSomeone elseWho does most of the cooking in your household? MeSomeone elseWho decides on most of the menus / meal types in your household?MeSomeone elseRight now, how much do the people and things around you support health, fitness, and / or behavior change? Selected Value: 1 1 – Not at all 10 – CompletelyHave you have been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries? *YesNoRight now, do you have any specific health concerns, such as illnesses, pain, and / or injuries? *YesNoRight now, are you taking any medications, either over-the-counter or prescription? *YesNoIf yes, please provide details.No need to add in supplement information unless you want to just medications.On a scale of 1-10, how would you rank your health right now? Selected Value: 1 1 – worst 10 – awesomeWhy? *Elaborate why you picked the numberIn an average week, how many hours do you spend for the following activities? 1. In paid employment? 2. Taking care of others? (e.g., children, person with a disability, older person) 3. At school or doing school work? 4. Doing other unpaid work? (e.g., housework, errands) 5. Traveling and / or commuting? Volunteering?On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness? Selected Value: 1 1 – My life is panicked and insane 10 – My life is perfectly calm and relaxedGiven all the demands of your life, what is your typical stress level on an average day? Selected Value: 1 Think about all the activities you’re involved in (e.g., work, school, caregiving, housework, travel). Then assess as best you can about your stress & recovery. 1 – no stress 10 – extreme stressOn average, how many hours per night do you sleep? *4 or fewer hours5 hours6 hours7 hours8 hours9 or more hoursHow do you normally cope with your stress?How READY are you to change your behaviors and habits? Selected Value: 1 How ready, willing, and able are you to change? Right now, on a scale of 1-10. 1 – not at all, 10 – completelyHow WILLING are you to change your behaviors and habits? Selected Value: 1 How ready, willing, and able are you to change? Right now, on a scale of 1-10. 1 – not at all, 10 – completelyHow ABLE are you to change your behaviors and habits? Selected Value: 1 How ready, willing, and able are you to change? Right now, on a scale of 1-10. 1 – not at all, 10 – completelyWhat do you expect from me as your coach?Please be as honest as possible. Helps me assess if we can be a right fit. What are you prepared to do to work towards your goals?Disclaimer *READ DESCRIPTION AND TYPE “I agree” if you want to proceed. Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and / or fitness consultation. 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. Submit
