Holistic Health Coaching Intake Questionnaire Please complete this form before your first session. Your responses help create a supportive, whole-person coaching experience. Personal Information Full Name* Date of Birth Phone Email* Preferred Pronouns (optional) What brings you to health coaching? What inspired you to seek health coaching at this time? What would you most like to improve in your life? If our work together is successful, what will be different six months from now? Current Health How would you rate your overall health? ExcellentVery GoodGoodFairPoor Medical conditions or diagnoses Current medications or supplements Current health concerns or symptoms Primary Care Provider (optional) Nutrition Describe a typical day of eating. Do you have any dietary restrictions or food sensitivities? NoYes If yes, please describe How much water do you drink daily? Less than 4 cups4–6 cups6–8 cupsMore than 8 cups Do you notice any of the following? Emotional eatingStress eatingSkipping mealsLate-night eatingNone of the above Physical Activity How often are you physically active? Daily3–5 times per week1–2 times per weekRarely Activities you enjoy What gets in the way of regular movement? Sleep Average hours of sleep each night Less than 55–67–8More than 8 How would you rate your sleep? ExcellentGoodFairPoor Check any that apply Difficulty falling asleepWake during the nightWake too earlyNever feel rested Stress & Emotional Wellness Current stress level 1 = Low Stress 10 = High Stress 12345678910 My biggest sources of stress are Healthy ways I currently manage stress Relationships Who are the most important people in your life? Do you feel supported? YesSomewhatNo Is there anything about your relationships you would like to improve? Work & Daily Life Are you satisfied with your work or daily responsibilities? Very SatisfiedSatisfiedNeutralDissatisfiedVery Dissatisfied Do you experience burnout? OftenSometimesRarelyNever Spiritual Wellness What gives your life meaning or purpose? Do you currently have any spiritual or mindfulness practices? PrayerMeditationReikiYogaJournalingNatureBreathwork Other spiritual or mindfulness practice Self-Care How often do you intentionally practice self-care? DailyWeeklyOccasionallyRarely What activities help you feel restored? Lifestyle Habits Caffeine None1 cup/day2–3 cups/dayMore than 3 cups/day Alcohol NeverOccasionallyWeeklyDaily Tobacco/Nicotine NoYes Screen time outside work Less than 2 hours2–4 hoursMore than 4 hours Your Strengths What are three strengths you possess? Wellness Goals What are your top three health and wellness goals? What obstacles might get in the way of reaching these goals? What support would help you be successful? Readiness for Change How ready are you to make healthy lifestyle changes? 1 = Not Ready 10 = Completely Ready 12345678910 Why did you choose that number? My Vision Imagine yourself one year from today living your healthiest life. How do you feel physically? How do you feel emotionally? How do you care for yourself? What does a typical day look like? Wellness Wheel Please rate your satisfaction in each area from 1 to 10. Physical Health 1 = Very Dissatisfied 10 = Very Satisfied 12345678910 Nutrition 1 = Very Dissatisfied 10 = Very Satisfied 12345678910 Sleep 1 = Very Dissatisfied 10 = Very Satisfied 12345678910 Energy 1 = Very Dissatisfied 10 = Very Satisfied 12345678910 Stress Management 1 = Very Dissatisfied 10 = Very Satisfied 12345678910 Emotional Wellness 1 = Very Dissatisfied 10 = Very Satisfied 12345678910 Relationships 1 = Very Dissatisfied 10 = Very Satisfied 12345678910 Career 1 = Very Dissatisfied 10 = Very Satisfied 12345678910 Finances 1 = Very Dissatisfied 10 = Very Satisfied 12345678910 Personal Growth 1 = Very Dissatisfied 10 = Very Satisfied 12345678910 Spiritual Wellness 1 = Very Dissatisfied 10 = Very Satisfied 12345678910 Fun & Recreation 1 = Very Dissatisfied 10 = Very Satisfied 12345678910 Additional Information Is there anything else you would like me to know before we begin working together?
