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Name*
First Last
Email Address*
Phone Number*
Video Chat ID (Skype, Google etc.)
How do you prefer I contact you?*
- Email
- Phone
- Skype or other video chat
- Text

What do you want to change?
Have you tried anything in the past to change your habits, your health, your eating, and / or your body?*
- Yes
- No
If so, what?
Which of those things worked well for you? (Even if you might not be doing it right now.)
Which of those things didn't work for you?
How, specically, would you like your habits, your health, your eating, and / or your body to be different?*
Have you already made changes to your habits, your health, your eating, and / or your body recently?*
- Yes
- No
If so, what?
If you were to consider making further changes to your habits, your health, your eating, and / or your body, what might those be?
Until now, what has blocked you or held you back from changing these things?
Right now, how would you rank your overall eating / nutrition habits?*
Eating Habits
Horrible 2 3 4 5 6 7 8 9 Awesome!!!
Why?
Are you regularly active in sports and / or exercise?
If so, approximately how many hours per week?*
- No Exercise
- Fewer than 5 hours
- 5-9
- 10-14
- 15-19
- 20 or more
What types of sports and / or exercise do you typically do?
Approximately how many hours a week do you do other types of physical activity? (e.g., housework, walking to work or school, home repairs, moving around at work, gardening)*
- Fewer than 5 hours
- 5-9
- 10-14
- 15-19
- 20 or more
What other types of movement and / or activities do you do?

What’s around you?
Tell me a bit about your environment.
Who lives with you? Check all that apply.
- Spouse or partner(s)
- Child(ren)
- Other family (e.g. parent, sibling, etc.)
- Roommate(s)
- Pet(s)
Do you have children? If yes, how many and what are their ages?
Who does most of the grocery shopping in your household? Check all that apply.
- Spouse or partner(s)
- Child(ren)
- Other family
- Roommate(s)
- Me
Who does most of the cooking in your household? Check all that apply.
- Spouse or partner(s)
- Child(ren)
- Other family
- Roommate(s)
- Me
Who decides on most of the menus / meal types in your household? Check all that apply.
- Spouse or partner(s)
- Child(ren)
- Other family
- Roommate(s)
- Me
Right now, how much do the people and things around you support health, fitness, and / or behavior change?
Support Change
Not At All 2 3 4 5 6 7 8 9 Completely

What’s your health like?
Have you have been diagnosed (currently 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 illnesses, pain, and / or injuries?*
- Yes
- No
Right now, are you taking any medications, either over-the-counter or prescription?*
- Yes
- No
On a scale of 1-10, how would you rank your health right now?*
Overall Health
Worst 2 3 4 5 6 7 8 9 Best
Why?
How are you spending your time?
In an average week, how many hours do you spend...
In paid employment?
At school or doing school work?
Traveling or commuting?
Taking care of others? (e.g. children, person with a disability, older person)
Doing other unpaid work? (e.g. housework, errands)
Volunteering?
Adding up all these things, how many total hours per week do you spend doing all these activities?
On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?*
Busy-ness
Panicked 2 3 4 5 6 7 8 9 Relaxed

How is your stress and recovery?
Think about all the activities you’re involved in (e.g., work, school, caregiving, housework, travel). Then assess as best you can:
Given all the demands of your life, what is your typical stress level on an average day?
Stress Level
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 your stress?*
How ready, willing, and able are you to change?
Right now, on a scale of 1-10
READY*
Not At All 2 3 4 5 6 7 8 9 Completely
WILLING*
Not At All 2 3 4 5 6 7 8 9 Completely
ABLE*
Not At All 2 3 4 5 6 7 8 9 Completely
Disclaimer*
Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and / or fitness consultation.
Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.
I have read the disclaimer

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