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VIP Client Intake Questionnaire

VIP Client Intake Questionnaire

Intake Questionnaire

Tell me about yourself
Name
First Last
Email
Date of Birth
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
What do you want out of this?
In general, what are your goals?
- Lose weight
- Add muscle
- Look and feel better
- Learn how to stay consistent
- Gain more energy and vitality
- Get off medications
- Get in control of my eating
- Learn how to maintain my weight, performance, and/or habits after achieving my goal
- Get stronger
- Improve sport performance
Please list all of your concerns about your eating habits, health, fitness and/or body…
Out of all the concerns, which ones feel the most important/urgent and why?
What do you expect?
What are you prepared to do to work towards your goals?
What do you expect from me as your coach?
What do you want to change?
Have you tried anything in the past to change your habits, your health, your eating, and/or body? (If so, what?)
Which of those worked well for you (even if you may not be doing it right now?)
How, specifically, would you like your 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? (if so, what?)
If you were to consider making further changes to your habits, your health, your eating, and/or you body, what might those be?
Until now, what has blocked you or held you back from changing these things?
Food And Eating
Right now, how would you rank your overall eating/nutrition habitsout of 10 – 1 being horrible, 10 being awesome.
Why?
How many glasses of water do you drink each day?
Right now, are following any particular diet? (eg, vegetarian/vegan, paleo, keto, low-carb, etc) if yes, what for, and how long have you been eating this way?
How many of your meals are made from home?
How often do you eat out or get takeaway?
How often do you shop for food?
How many of your meals each day have 1-2 portions of colourful vegetables?
How many of your meals each day have 1-2 palm-sized potions of lean protein (meat, fish, eggs, etc)
If you're currently exercising or involved in a sport, how many hours are you training per week?
What types of sports and/or exercise do you typically do?
What exercise equipment do you have access to?
On a scale of 1-10 how would you rank your food preparation skills right now? (1 = Terrible, 10 = Expert chef)
(1 = Terrible, 10 = Expert chef)
What other types of movement and/or activities do you do?
What's Around You?
Who else lives with you?
- Spouse or partner
- Children
- Other family
- Room mates
- Pet (s)
Do you have children – if yes, how many and what are their ages?
Who does most of the grocery shopping in your house-hold?
- Me
- Spouse or partner
- Children
- Room mate
- Other family
Who does most of the cooking in your house hold?
- Me
- Spouse or partner
- Children
- Room mate
- Other family
Right now, how much do the people and things around you support your health, fitness, and behavior change? 1 = not at all, 10 = completely
What's Your Health Like?
Right now, are you taking any medications, either over the counter or prescription? If so, what are you taking and why?
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries? If so, detail everything below:
Do you have any known/diagnosed food allergies or intolerances? (If yes what are those?)
Do you have any suspected or possible food allergies or intolerances? (if yes, what are those?)
How often do you have a bowel movement?
On a scale of 1-10 (1 being horrible, 10 being awesome) how would you rank your health right now?
How are you spending your time?
In an average week, how many hours do you spend in paid employment?
Taking care of others? (children, person with disability, older person)
At school or doing school work?
Doing other unpaid work? (household, errands, etc).
Travelling and/or commuting?
Volunteering?
Adding up all these total hours, how many hours per week do you spend doing all these total activities?
On a scale of 1-10 (1 being panicked and insane, 10 being perfectly calm and relaxed) how do you feel about your schedule, time use, and overall busy-ness?
How is your stress and recovery?
Given all the demands on your life, what is your typical stress on an average day? (1 no stress, 10 extreme stress).
On average, how many hours per night do you sleep?
How do you normally cope with your stress?
How Ready, Willing & Able are you to change?
How READY are you to change your behaviours and habits? (1= not at all. 10 = Completely)
1= not at all. 10 = Completely
How WILLING are you to change your behaviours and habits? (1= not at all. 10 = Completely)
1= not at all. 10 = Completely
How ABLE are you to change your behaviours and habits? (1= not at all. 10 = Completely)
1= not at all. 10 = Completely
DISCLAIMER: Please recognise 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 is not to be followed without prior approval of your doctor. If you choose to use this information without approval, you agree to accept full responsibility of your decision.
- I understand
Client Signature (Print Name)
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Phone
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