General Information

Name

First Name

Last Name

Today's Date

YYYY

Date of Birth

YYYY

Phone

(###)

###

####

Marital Status

Number of Children (if any)

Ages of Children

How many boys/girls? Grandchildren?

Occupation and length of time at current position?

If not formally employed, please describe an average day in your life or explain what you spend your time on.

My objectives are (check all that apply):

Gaining strength

Healthier body (fat loss)

Improving flexibility

Emotional/stress eating

Relationship with food

Body Image

Food cravings

Improve balance

Increased energy/stamina

Background on issues standing between you and your goals:

Please go into detail about the MOST concerning issue that is your biggest obstacle.

Thinking of your objectives, what efforts have you taken, other programs you have tried and/or diets?

Have you examined the emotional issues that may be contributing to you not being able to reach your objectives (listed above).

Try to turn inward. Without blaming your outside life (being busy, kids, work, etc.), have you asked yourself about what underlying emotions might be present in your life/body that are keeping you from your goals?

I think the emotional issues might be:

Even if you're not sure, please write what first comes to mind when you ask yourself this question: What emotions might be keeping me from reaching my goals?

I think my biggest challenges to overcoming those emotions and/or issues might be:

The changes I would like to see in myself and/or my life are:

My Life

My life is like _____________.

Finish the sentence with what you feel life is like.

The activités that give me the most enjoyment, sense of wellbeing, fulfillment, contentment, and purpose are__________________.

Please list these WITH the reasons WHY they bring you these feelings.

The key people in my life, my relationship to them, and their significance in my life are:

List names, who they are to you, why they are significant.

Please put a check by the areas in your life that you feel are going well.

check all that are going well for you CURRENTLY

Money & Finances

Immediate Family

Health, Wellbeing & Fitness

Creativity & Fun

Personal Relationships

Personal Growth & Spiritual Development

Career, Vocation and/or Business

Of the above categories, which is going the best for you?

Of the above categories, which is not going well for you?

I spend my leisure time by:

I would describe my spiritual life like this:

The words that would best describe me when I feel on top of the world would be:

At least three words, please.

The words that would best describe me when I feel trampled by life would be:

At least three words, please.

The words I would use to describe myself in general would be:

If someone asked you to describe yourself in three words what would you say?

The words my friends would use to describe me would be:

At least three words, please.

This is my definition of success:

Nutrition

I would describe my eating habits by saying this:

Do you eat compulsively and/or in response to emotions?

The foods I crave and my comfort foods include:

Medical History

The medical issues/conditions I have are:

I am currently being treated for the following medical conditions (physical and/or emotional) by (medical doctor, nutritionist, acupuncturist, chiropractor, etc.):

Please list condition and current form of care.

My current weight (in lbs) is:

Height in inches:

Health Management

Rate your overall HEALTH (0-10 scale, 0 = no health issues, 10 = multiple severe health concerns)

Rate your STRESS (0-10 scale, 0 = no stress, 10 = extremely stressed)

Rate your ENERGY level (0-10 scale, 0 = lots of energy, 10 = low energy)

Rate your SLEEP quality (0-10 scale, 0 = sleep well, 10 = problems with sleep)

Rate your HAPPINESS on an average day (0-10 scale, 0 = happy, 10 = depressed)

My stress reduction techniques include:

Please list at least three ways you reduce stress.

History

My greatest accomplishments to date would include:

My biggest disappointments to date would include:

The hardest thing(s) I have had to overcome in my life would be:

The last major transition (retirement, empty nest, job promotion, new job, family health, etc.) in my life would have been in ________ when ______________ happened.

Please be specific about the reasons why this event was such a huge transition for you.

I would describe my relationship with my mom as a child and as an adult as:

I would describe my relationship with my dad as a child and as an adult as:

I would describe my relationship with my siblings as a child and as an adult as:

To summarize my life, I would say this:

Expectations & Goals

My expectations and goals are:

Please clearly list your expectations of me as your coach. Please list clear and achievable goals.

Coaching Intake

khailohwellness@gmail.com • PO BOX 313 MONTPELIER, ID 83254