Tell me about yourself… About you Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Gender Male Female Prefer not to say Email * Phone * (###) ### #### Preferred Contact Method Text Email Phone Zoom In-person Emergency Contact * First Name Last Name Emergency Contact Phone (###) ### #### What do you want? In general, what are your goals? Lose Weight/Fat Gain Weight Maintain Weight Add Muscle Improve Overall Health Improve Physical Fitness Look Better Feel Better Have More Energy/Vitality Healthy Aging Get Control of Eating Habits Get Stronger Decrease Medications Other What do you want to change? How, specifically, would you like your habits, your health, your eating, and/or your body to be different? * Of all the changes you want to make, which seem the most important/urgent? Have you tried anything in the past to change your habits, your health, your eating, and/or your body? Which of those things worked well for you? Which of those things didn't work well for you? Until now, what has prevented you from making these changes? What are you doing right now? How would you rate your overall eating/nutrition habits? Horrible 2 3 4 5 6 7 8 9 Awesome Are you regularly active in sports or exercise? No Yes Approximately how many hours per week less than 5 5-9 10-14 15-19 20+ What types of sports/activities do you typically do ? Approximately how many hours a week do you do other activities? e.g. housework, walking to work or school, walking the dog, gardening, yard work Fewer than 5 hours 5-9 10-14 15-19 20+ What other types of movement/activities do you do? What's around you? Who lives with you? Spouse or Partner Roommate(s) Pet(s) Other Family (Grandparents, Parents, Siblings, , etc) Other Children How many, and what are their ages? Who does the majority of grocery shopping in your household? Me Spouse or Partner Roommate(s) Child(ren) Other Family Who does the majority of the cooking in your household? Me Spouse or Partner Roommate(s) Child(ren) Other Family Who decides most of the menus/meal types in your household? Me Spouse or Partner Roommate(s) Child(ren) Other Family How much do the other people and things around you support health and fitness and/or behavior change? Not at all 2 3 4 5 6 7 8 9 Completely What's your health like? Have you been diagnosed (now, or in the past) with any significant medical condition(s) and/or injuries? Yes No Right now, do you have any specific health concerns, such as illness, pain, and/or injuries? Yes No Right now, are you taking any medications, either over-the-counter or prescription? Yes No How would you rate your health right now? Worst 2 3 4 5 6 7 8 9 Awesome Why? How are you spending your time ? How do you feel about your schedule, time, use, and overall busy-ness? My llife is packed and insane 2 3 4 5 6 7 8 9 My life is perfectly calm and relaxed In an average week, how many hours do you spend in paid employment? In an average week, how many hours do you spend at school or doing school work? In an average week, how many hours do you spend travelling and/or commuting? In an average week, how many hours do you spend taking care of others (children/elderly)? In an average week, how many hours do you spend doing other unpaid work (housework/errands)? In an average week, how many hours do you spend volunteering? How is your stress and recovery? Given the demands of your life, what is your typical stress level on an average day? No Stress 2 3 4 5 6 7 8 9 Extreme Stress On average, how many hours per night do you sleep? 4 or fewer hours 5 hours 6 hours 7 hours 8 hours 9 hours 10 or more hours How do you normally cope with stress? How ready, willing, and able are you to change? How READY are you to change your behavior and habits? Not at all 2 3 4 5 6 7 8 9 Completely How WILLING are you to change your behavior and habits? Not at all 2 3 4 5 6 7 8 9 Completely How ABLE are you to change your behavior and habits? Not at all 2 3 4 5 6 7 8 9 Completely What do you expect? What do you expect from me as your coach? What are you prepared to do to work towards your goals? DISCLAIMER How Did You Hear About Future You Nutrition? Future You Nutrition Website AIM Human Performance INOVA IPMDC Other Thank you! I’ll be reaching out to you soonest!
