Health & Wellness Coaching Initial Assessment Form Part 1: Question Title * 1. I want to address the following areas with my coach(check up to five areas, rate from most important to least important): Improve energy Improve productivity Increase physical activity Lose weight Maintain current weight Improve eating habits Improve health risks or medical conditions Reduce need for medication Improve sleep Improve work/school/life balance Manage stress better or reduce stress Improve personal relationships Other (please specify) Question Title * 2. How often are you physically active, on average, per week?(physical activity is defined as continuously moving your body 15 minutes or more) 6-7 times per week 4-5 times per week 2-3 times per week 1-2 times per week Question Title * 3. Rate the importance to me of regular physical activity: 0 10 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 4. My readiness to make changes or improvements to reach or sustain regular physical activity: I am already maintaining good physical activity levels consistently (6 mos. +) I recently starting working on this I am planning on changing this month I am planning a change to start in the next 6 months I have no present interest in making a change Question Title * 5. My confidence level in my ability to reach and sustain regular physical activity1 (lowest confidence) and 10 (highest confidence) 1 10 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 6. Do you have any limitations in exercising? Yes No Other (please specify) Question Title * 7. How often do you eat breakfast (more than just a roll and cup of coffee)? I eat breakfast every day I eat breakfast most mornings I eat breakfast 2-3 times per week I seldom or never eat breakfast Question Title * 8. How often do you eat “junk” snack foods between meals?Ex. Pastries, candy, ice cream, cookies Three or more times per day Eat mostly the high fat foods Eat both about the same Eat mostly low fat foods, some high fat Eat only low fat foods Question Title * 9. How many servings of fruits and vegetables do you eat daily?A serving is: 1 cup fresh, ½ cup cooked, 1 medium fruit, or ¾ cup juice One or less Two daily Three daily Four daily Five or more Question Title * 10. How many 8 ounce glasses of water do you drink on average per day? None 1-2 glasses 3-5 glasses 6-8 glasses Done