Personal Information

Today's Date:
Your Name:
Email address:
Gender: M F 
Date of Birth:
City/State of Residence:
Relationship Status: SingleMarriedPartnerSeparatedDivorcedWidowed
Number of Children:
Ages of Children:

Life Satisfaction

Sense of Purpose -- I feel a strong sense of purpose in life: ---NeverRarelySometimesFrequentlyMost of the Time

Joy -- I feel a deep satisfaction or joy in my life: ---NeverRarelySometimesFrequentlyMost of the Time

Work Satisfaction -- Indicate level of satisfaction: ---DissatisfiedNot Very SatisfiedMostly SatisfiedVery SatisfiedNot Applicable

Gratitude -- I feel grateful and appreciative for what I have: ---NeverRarelySometimesFrequentlyMost of the time

Personal Relationship Satisfaction - Indicate level of satisfaction: ---DissatisfiedNot very satisfiedMostly satisfiedVery satisfiedNot applicable

My Importance -- Rate the importance to me of having a high level of life satisfaction: --- Not important at allSomewhat importantVery importantMost important goal in my life right nowOther
Other, describe here:

My Confidence -- My confidence level in my ability to reach and sustain a high level of life satisfaction is: ---Not at all confidentSomewhat confident Very confidentCompletely confidentOther
Other, describe here:

My readiness to change -- My readiness to make changes or improvements in my life satisfaction: ---I am already maintaining good life satisfaction consistently (6 mos +)I recently started working on thisI am planning a change starting this monthI am planning a change to start in the next six monthsI presently have some interest in making a changeI am not ready or willing to work on this area at this time

Coaching Priorities

I want to address the following areas with my coach (check all that apply for each section):

Overall:
Improve my well-being Improve my family's well-being Improve energy  Improve productivity Other 
Other, describe here:

Physical:
Increase Physical activity Manage or prevent injury Lose weight Manage or maintain current weight Improve eating habits Improve health risks or medical conditions  Reduce need for medication Other 
Other, describe here:

Mental and Emotional:
Improve work/life balance Improve sleep Manage stress better or reduce stress Reduce or quit smoking Improve finances Improve personal relationships Manage drug or alcohol issues Other 
Other, describe here:

Energy

In a work typical day, what percentage of the time are you (all three should add up to 100%) at the following levels of energy (meaning physical and mental vigor or vitality):
Best energy:
Average energy:
Low energy:

When you are not working, what percentage of the time are you at:
Best energy:
Average energy:
Low energy:

Energy boosters -- Select the top three things that boost your energy:
Healthy Sleep Regular exercise Healthy eating habits Stress management, relaxation, or fun activities Healthy mindset Positive family and personal relationships Positive work relationships Maintaining a healthy weight Maintaining good physical health Job satisfaction Spiritual activities Healthy Finances Other 
Other, describe here:

Energy Drains -- Select the top three things that are currently draining your energy:
Poor or insufficient sleep Too little exercise Unhealthy eating habits Stress Weight management issues Physical health issues Pessimism or emotional issues Work issues Family or relationship issues Financial issues Other 
Other, describe here:

My Importance -- Rate the importance to me of being at my best energy level at least 50% of the time: ---Not important at allSomewhat importantVery importantMost important goal in my life right nowOther
Other, describe here:

My Confidence -- My confidence level in my ability to reach and sustain my best energy levels at least 50% of the time is: ---Not at all confidentSomewhat confidentVery confidentCompletely confidentOther
Other, describe here:

My Readiness to Change -- My readiness to make changes or improvements in my energy levels: ---I am already maintaining good energy levels consistently (6 mos +)I recently started working on thisI am planning a change starting this monthI am planning a change to start in the next six monthsI presently have some interest in making a changeI am not ready or willing to work on this area at this time

Weight

Height (no shoes): feet inches
Waist measurement in inches:
Current weight (no shoes):
Current Bodyfat percentage (if known):
Weight one year ago:
Weight two years ago:
Weight five years ago:
Weight ten years ago:

Describe any weight loss (or gain) efforts or programs pursued in the past 10 years:

My Importance -- Rate the importance to me of reaching and sustaining a healthy weight: ---Not important at allSomewhat importantVery importantMost important goal in my life right nowOther
Other, describe here:

My Confidence: My confidence level in my ability to reach and sustain a healthy weight: ---Not at all confidentSomewhat confidentVery confidentCompletely confidentOther
Other, describe here:

My Readiness to Change -- My readiness to make changes or improvements to reach and sustain a healthy weight: ---I am already at a healthy weight and have been managing my weight consistently (6 mos +)I recently started working on this I am planning a change starting this monthI am planning a change to start in the next six monthsI presently have some interest in making a changeI am not ready or willing to work on this area at this time

Exercise

Describe any current limitations on physical activity (e.g. injuries, illness, medical conditions):

Describe any previous limitations on physical activity (within past five years):

Regular physical activity:
Do you currently participate in regular physical activity? Y N 
If Yes, describe frequency and type of exercise in which you currently engage::

Other physical activity -- How many minutes in an average day are you physically active? (e.g. gardening, physical labor, using stairs, walking, etc.)

My Importance -- Rate the importance to me of regular physical activity: ---Not important at allSomewhat importantVery importantMost important goal in my life right nowOther
Other, describe here:

My Confidence -- My confidence level in my ability to reach and sustain regular physical activity: ---Not at all confidentSomewhat confidentVery confidentCompletely confidentOther
Other, describe here:

My Readiness to Change -- My readiness to make changes or improvements to reach and sustain regular physical activity: ---I am already exercising regularly and consistently (6 mos +)I recently started working on thisI am planning a change starting this monthI am planning a change to start in the next six monthsI presently have some interest in making a changeI am not ready or willing to work on this area at this time

Nutrition

Breakfast: How often do you eat breakfast? ---Seldom or neverTwo or three times per weekMost morningsEvery day

If you eat breakfast, describe what you typically have:

Snacks: Do you typically have snacks, and if so, what do you eat for snacks, and what time(s) of day do you normally snack? Y N 
If Yes, describe here:

Eating out: How many meals per week do you typically eat “out”? ---None1-34-7Most of my meals are eaten out

Fast Food: Do you eat meals or snacks at or from fast food restaurants?? Y N 

Vegetables: How many fruits and vegetables do you eat (not counting fried ones) in an average day? ---None1-23-45 or more

Protein: What are your primary sources of protein?

How many servings (four ounces) of protein do you consume in an average day? ---None1-23-44 or more

Water intake: How many eight ounce servings of water do you drink on average per day? ---None1-2 servings3-5 servings6 or more servings

Soft drinks: Do you consume non diet or other sugary soft drinks? Y N 
If yes, please describe type, amount and frequency:

Diet soft drinks: Do you consume diet soft drinks? Y N 
If yes, please describe type, amount and frequency:

How often do you consume caffeinated beverages: ---Rarely or Never1-2 a dayMore than 3 a dayOther
Other, describe here:

Alcohol:
How many alcoholic drinks do you usually have per weekday (one ounce liquor, 12 ounces beer, or 4 ounces or wine)? ---I never or rarely drink alcohol on weekdays1-2 servings per weekdayMore than 2 servings per weekday

How many alcoholic drinks do you usually have per weekend day? ---I never or rarely drink alcohol on weekends 1-2 servings per weekend days More than 2 servings per weekend day

My Importance: Rate the importance to me of consuming healthy food and drinks in appropriate quantities most of the time: ---Not important at allSomewhat importantVery importantMost important goal in my life right nowOther
Other, describe here:

My Confidence: My confidence level in my ability to consume healthy food and drinks in appropriate quantities most of the time: ---Not at all confidentSomewhat confidentVery confidentCompletely confidentOther
Other, describe here:

My Readiness to Change -- My readiness to make changes or improvements to consume healthy food and drinks most of the time: ---I am already consuming healthy food and drinks in appropriate quantities regularly and consistently (6 mos +)I recently started working on thisI am planning a change starting this monthI am planning a change to start in the next six monthsI presently have some interest in making a change I am not ready or willing to work on this area at this time

Health

In general, my overall health is: ---PoorFairGoodVery GoodExcellent

Physician Relationship - Do you have a primary care doctor whom you trust and see regularly? ---NoSomewhatYes

Physician Exam -- When was your last physical exam: ---5 or more years ago3-4 years ago2 years agoWithin the last year

Is your blood pressure within normal range? ---YesNoDon't know

Is your cholesterol within normal range? ---YesNoDon't know

Do you take any medications for any of the above or other conditions? Y N 
If Yes, list here:

Do you take any vitamins? Y N 
If Yes, list here:

Do you take any supplements? Y N 
If Yes, list here:

Do you currently use any tobacco products? Y N 

Have you ever used any tobacco product? Y N 

Are there any other matters related to your health that you would like to share, or that you would like to change or improve? Y N 
If Yes, describe here:

Are there any matters related to your family health history that you would like to share? Y N 
If Yes, describe here:

My Importance: Rate the importance to me of improving or changing some aspect of my health: ---Not important at allSomewhat importantVery importantMost important goal in my life right nowOther
Other, describe here:

My Confidence: My confidence level in my ability to improve or change some aspect of my health: ---some aspect of my health: Not at all confidentSomewhat confidentVery confidentCompletely confidentOther
Other, describe here:

My Readiness to Change -- My readiness to make changes or improvements to improve some aspect of my health: ---I am already doing things to influence any aspects of my health that concern me (6 mos +)I recently started working on thisI am planning a change starting this monthI am planning a change to start in the next six monthsI presently have some interest in making a changeI am not ready or willing to work on this area at this time

Stress

Coping -- How well do you feel you are coping with your current stress load? ---Feel unable to cope anymoreOften have trouble copingSometimes have trouble copingUsually cope well

Stress -- Mark any symptoms below that apply to you:
Minor problems tend to throw me for a loop these days I find it difficult to get along with people I used to enjoy Nothing seems to give me pleasure anymore I am unable to stop thinking about my problems I feel frustrated, angry, or impatient much of the time I feel tense or anxious much of the time None of the above really apply to me 

Sleep -- How many hours of sleep do you get on average? ---Less than 66-77-8More than 8

Emotional issues -- During the past four weeks, to what extent have you accomplished less than you would like in your work or other daily activities as a result of emotional issues, such as feeling depressed or anxious? ---ExtremelyQuite a bitModeratelySlightlyNot at all

Personal loss -- Have you suffered a personal loss or misfortune in the past year (e.g. job loss, disability, separation or divorce, serious illness or death of someone close to you)? ---NoYes, one such lossYes, two or more losses

Social Support -- Do you have friends/family with whom you can share problems and get help if needed? Y N 

Feelings -- These next questions are about how you feel things have been during the past four weeks. For each question, please give the one answer that comes closest to describing the way you have been feeling. How much of the time during the past four weeks:
Have you felt calm and peaceful? ---None of the timeA little of the timeSome of the timeA good bit of the timePretty much all of the time
Did you have a lot of energy? ---None of the timeA little of the timeSome of the timeA good bit of the timePretty much all of the time
Have you been a happy person? ---None of the timeA little of the timeSome of the timeA good bit of the timePretty much all of the time
Did you take the time to relax and have fun daily? ---None of the timeA little of the timeSome of the timeA good bit of the timePretty much all of the time
Have you felt downhearted or blue? ---None of the timeA little of the timeSome of the timeA good bit of the timePretty much all of the time
Have you felt worthless, inadequate, or unimportant? ---None of the timeA little of the timeSome of the timeA good bit of the timePretty much all of the time
Been feeling low in energy, slowed down? ---None of the timeA little of the timeSome of the timeA good bit of the timePretty much all of the time

My Importance: Rate the importance to me of reaching and sustaining optimal mental and emotional fitness: ---Not important at allSomewhat importantVery importantMost important goal in my life right nowOther
Other, describe here:

My Confidence: My confidence level in my ability to reach and sustain optimal mental and emotional fitness: ---Not at all confidentSomewhat confidentVery confidentCompletely confidentOther
Other, describe here:

My Readiness to Change -- My readiness to reach and sustain optimal mental and emotional fitness: ---I am already doing things to reach and sustain optimal mental and emotional fitness (6 mos +)I recently started working on thisI am planning a change starting this monthI am planning a change to start in the next six monthsI presently have some interest in making a changeI am not ready or willing to work on this area at this time

Additional Information

Is there anything else you'd like to share that may be relevant to your wellness goals or your well-being?

Enter the Text above here: