Health Coaching Questionnaire

This questionnaire will allow you to reflect on your current health situation and help you decide how you want to master your health and wellness. It's a key step in your success!

Please complete the questionnaire at least one day before your first session.
All your information will remain confidential.

Question Title

1. Basic Information

Name

Age

Sex

Relationship Status

Children (# and ages)

Current weight (optional):

Question Title

2. Mark which areas of wellness you want to work on. For the areas you choose yes, indicate the priority level, and your level of confidence in achieving the goal.

	Work on this?	Priority Level (1 = high priority, 2 = medium priority, 3 = low priority)	Confidence Level (1 = very confident, 2 = fairly confident, 3 = not confident)
Improve life satisfaction	Improve life satisfaction Work on this? menu	Improve life satisfaction Priority Level (1 = high priority, 2 = medium priority, 3 = low priority) menu	Improve life satisfaction Confidence Level (1 = very confident, 2 = fairly confident, 3 = not confident) menu
Increase Energy	Increase Energy Work on this? menu	Increase Energy Priority Level (1 = high priority, 2 = medium priority, 3 = low priority) menu	Increase Energy Confidence Level (1 = very confident, 2 = fairly confident, 3 = not confident) menu
Improve physical activity	Improve physical activity Work on this? menu	Improve physical activity Priority Level (1 = high priority, 2 = medium priority, 3 = low priority) menu	Improve physical activity Confidence Level (1 = very confident, 2 = fairly confident, 3 = not confident) menu
Improve eating habits	Improve eating habits Work on this? menu	Improve eating habits Priority Level (1 = high priority, 2 = medium priority, 3 = low priority) menu	Improve eating habits Confidence Level (1 = very confident, 2 = fairly confident, 3 = not confident) menu
Decrease Stress	Decrease Stress Work on this? menu	Decrease Stress Priority Level (1 = high priority, 2 = medium priority, 3 = low priority) menu	Decrease Stress Confidence Level (1 = very confident, 2 = fairly confident, 3 = not confident) menu
Weight Management	Weight Management Work on this? menu	Weight Management Priority Level (1 = high priority, 2 = medium priority, 3 = low priority) menu	Weight Management Confidence Level (1 = very confident, 2 = fairly confident, 3 = not confident) menu
Improve one or more health conditions	Improve one or more health conditions Work on this? menu	Improve one or more health conditions Priority Level (1 = high priority, 2 = medium priority, 3 = low priority) menu	Improve one or more health conditions Confidence Level (1 = very confident, 2 = fairly confident, 3 = not confident) menu

Health Coaching Questionnaire

Question Title

1. Basic Information

Question Title

2. Mark which areas of wellness you want to work on. For the areas you choose yes, indicate the priority level, and your level of confidence in achieving the goal.

Question Title

3. What is the first area you would like to work on?

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4. How will friends and family support you?

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5. How would you describe your ideal personal coach?

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* 1. Basic Information

Question Title

* 2. Mark which areas of wellness you want to work on. For the areas you choose yes, indicate the priority level, and your level of confidence in achieving the goal.

Question Title

* 3. What is the first area you would like to work on?

Question Title

* 4. How will friends and family support you?

Question Title

* 5. How would you describe your ideal personal coach?

1. Basic Information

2. Mark which areas of wellness you want to work on. For the areas you choose yes, indicate the priority level, and your level of confidence in achieving the goal.

3. What is the first area you would like to work on?

4. How will friends and family support you?

5. How would you describe your ideal personal coach?