Name
Age
Gender
Select
Male
Female
Others
Email (Optional)
Phone Number
Preferred Date
Preferred Mode of Communication
Select
Phone Call
Whats app Call
Video Call
In-Person (visit the office)
Are you currently taking any medications? If yes, please list them.
Do you have any allergies?
Have you had any surgeries or major injuries? If yes, please provide details.
What is your current occupation?
How would you describe your daily stress levels on a scale of 1 to 10? (where 1 is least stressed and 10 is highly stressed)
Select
1
2
3
4
5
6
7
8
9
10
How many hours of sleep do you get on average per night?
How often do you consume tobacco, smoke or consume alcohol?
Select
Never
Rarely (once in a month or less)
Occasionally (few times in a month)
Once a week
2-3 times a week
More than 3 times a week
Everyday
Do you have any dietary restrictions or preferences? (e.g., vegetarian, vegan, gluten-free)
How often do you eat out or consume processed foods?
Select
Never
Rarely (once in a month or less)
Occasionally (few times in a month)
Once a week
2-3 times a week
More than 3 times a week
Everyday
What is your current level of physical activity? (Sedentary, Light, Moderate, High)
Select
Sedentary: little to no physical activity.
Light: light activity, like casual walking.
Moderate: moderate activity, like brisk walking.
High: high-intensity activity, like running.
What types of exercise do you currently engage in? (e.g., yoga, running, weightlifting)
Do you have any physical limitations or injuries that affect your ability to exercise?
What are your top three health goals? (for eg. improve physical fitness, enhance nutrition, boost mental wellbeing etc.)
Why are these goals important to you?
What has motivated you to seek health coaching now?
Have you tried any health or wellness programs in the past? If yes, what worked and what didn’t?
Is there anything else you would like to share about your health journey?
What are your expectations from this health coaching program?
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