Initial Assessment Triage Questionnaire

Tell Me About Yourself

Name

First Last

Date of Birth

Gender

Male
Female

Staying in Touch

Email

Mobile Phone

Home Phone

Emergency Contact Name

First Last

Emergency Contact Phone

How do you prefer me to contact you?

What Do You Want?

In general, what are your goals? Check all that apply.

Please share all of your concerns about your health, eating habits, fitness and/or body.

Out of all of the above concerns, which ones feel more important / urgent?

Why do they feel the most important / urgent?

What Do You Expect?

What do you expect from me as your coach?

What are you prepared to do to work towards your goals?

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? 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 well for you?

How, specifically, 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? 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?

1=Horrible / 10=Awesome

Why?

Are you regularly active in sports and / or exercise?

Yes
No

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?

What’s around you?

Who lives with you? Check all that apply.

Spouse or partner(s)
Roommates(s)
Child(ren)
Pet(s)
Other family (e.g. parent, grandparent, sibling, etc.)

Do you have children?

Yes
No

If yes, how many and what are their ages?

Who does most of the grocery shopping in your household? Check all that apply.

Me
Spouse or partner(s)
Roommate(s)
Child(ren)
Other family

Who does most of the cooking in your household? Check all that apply.

Me
Spouse or partner(s)
Roommate(s)
Child(ren)
Other family

Who decides on most of the menus / meal types in your household? Check all that apply.

Me
Spouse or partner(s)
Roommate(s)
Child(ren)
Other family

Right now, how much do the people and things around you support health, fitness, and / or behavior change?

1=Not at all / 10=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

Right now, how much do the people and things around you support health, fitness, and / or behavior change?

1=Worst / 10=Awesome

Why?

How Are You Spending Your Time?

Please indicate the approximate hours spent in a given week on each of the following activities:

In paid employment?

Taking care of others? (e.g., children, person with a disability, older person)

At school or doing school work?

Doing other unpaid work? (e.g., housework, errands)

Traveling and / or commuting?

Volunteering?

Adding up all these things, how many total hours per week do you spend performing all of these activities?

On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?

1=MY LIFE IS PANICKED AND INSANE 10=MY LIFE IS PERFECTLY CALM AND RELAXED

How Is Your Stress & 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?

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, and able are you to change?

Right now, on a scale of 1-10:

How READY are you to change your behaviors and habits?

1=Not at all / 10=Completely

How WILLING are you to change your behaviors and habits?

1=Not at all / 10=Completely

How ABLE are you to change your behaviors and habits?

1=Not at all / 10=Completely

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.

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PRECISION NUTRITION / 1TO1 FITNESS

Welcome to Nutrition & Body Transformation Coaching at 1TO1 FITNESS! Please complete the form below to get started. Your coach, Andrea, will be in touch shortly to schedule your first call.

If you begin completing this form, but do not have time to finish it, you can scroll to the bottom of the page and click “Save and Continue Later.” An email will be sent to you with a link to your partially completed QUESTIONNAIRE.

Tell Me About Yourself

Staying in Touch

What Do You Want?

What Do You Expect?

What Do You Want to Change?

What’s around you?

What's Your Health Like?

How Are You Spending Your Time?

How Is Your Stress & Recovery?

How ready, willing, and able are you to change?