detailed intake form

Brain, Body, Soul questionnaire

Name *

First

Last

Email *

Age, height and weight *

The following questions are a way to get us started. Don’t worry about answering them “perfectly.” In fact, just writing the first things that come to your mind can be most productive. Take as much time as you need to compose your responses. The more detail you provide, the better. And please be as honest (with yourself and with your answers) as you are able.
Change takes courage. I will support you without judgement.

What are your top five health and wellness goals? *

What is not working in your life right now regarding your health and wellbeing? *

What would you like to get out of lifestyle coaching? *

What challenges are you having in regards to your health and fitness? *

I’d like to know about your current support system. Please share more about the practitioners, medical doctors and specialists, nutritionists, therapists, naturopaths, trainers, friends and family who support your health and well-being. *

What is your self-talk like? Do you tend to be kind to yourself or do you tend to be more negative? *

What are your beliefs about your ability to make changes? *

What aspects of your home-life and environment support your health and well-being? What aspects detract? *

What aspects of your work-life and environment support your health and well-being? What aspects detract? *

Please tell me a little about your interests, hobbies, and passions. *

Describe your current physical activities, including frequency, duration and types. *

Rate the importance of regular physical activity to your quality life: 1—not important through 10—most important thing in my life *

Do you have any limitations in movement/exercise? (i.e., pain, reduced mobility, medical diagnosis, etc.) *

On average, how many hours per night do you sleep? Describe the quality of that sleep. *

On a scale from 1 - 5 how would you rate your current stress level? 1—not stressed at all through 5—very high level of stress/anxiety *

Do you drink alcohol? If so, how much and what type *

Do you use recreational drugs? If yes, please explain *

How much water do you drink? *

Do you have any digestive issues (constipation, diarrhea, irritable bowel...)? Do you have a bowel movement daily? *

Do you have any skin issues? If yes, please explain condition and when it began *

Is there anything else you would like me to know? *

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Brain, Body, Soul questionnaire

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