Springfield Health Coaching: Nutritionists & Dietitians

Name

First Last

Email

Phone

DOB:

How, specifically, would you like your habits, your health, your eating and/or your body to be different?

Out of all of the changes you’d like to make, which ones feel most important/urgent?

Have you tried anything in the past (or recently) to change your habits, your health, your eating, and/or your body? If so, what?

Which of these things worked well and why?

Which of these things didn’t work well and why?

Have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries?

When were you diagnosed, or when did the injury occur?

What have you tried (medication and lifestyle) to improve your health and well-being?

Do you currently take any medications or supplements? Please list:

Are there any helpers, healer, or therapies with which you are currently involved?

Are you regularly active in sports and /or exercise? If so, approximately how many hours per week?

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)

What other types of movement and/or activities do you do?

If we were having this conversation one year from today, what would have had to happen in that time for you to be successful in our program? What would your goals be for doing our program?

What do you think would prevent you from achieving those goals?

What or who is your support system?

In a given week how many times do you eat out?

In a given week how many times do you drink caffeine?

In a given week how many times do you drink alcohol?

In a given week how many times do you smoke?

In a given week how many times do you crave sugar?

In a given week how many times do you ever feel fatigued?

Do you have any allergies or sensitivities?

On average, how many hours per night do you sleep?

On a scale of 1-10, how ready are you to change your behaviors and habits?

On a scale of 1-10, how willing are you to change your behaviors and habits?

On a scale of 1-10, how able are you to change your behaviors and habits?

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Do you feel pain in your chest when you do physical activity?

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Do you know of any other reason why you should not do physical activity?

Is there anything additional you would like to share?

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Medical Fitness Assessment

Medical Fitness Assessment

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