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Auspicious Essentials Coaching Intake Form

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Auspicious Essentials Coaching Intake Form

Hello and thank you for choosing to work with Auspicious Essentials. This is the very start of our very exciting journey together.

To get things rolling I would be grateful if you could fill in all the information in this form. This helps me get a good understanding of your current fitness level, goals, diet and generally a bit about you.

Understanding your current situation and goals is one of the most important things in your transformation journey.

By learning more about your lifestyle and your habits, I can take better care of you and make sure coaching is a good fit for your goals and individual needs.

With this information, I'll share essential nutrition information, helpful tips and recipes, and plenty of healthy strategies to achieve your goals.

Then, together, we create a comprehensive action plan based upon your unique health and nutrition goals to set you up for nutrition and wellness success.

The more information you can supply the better I can make our system more personalized for you and in order to create a great program.

All information given is kept confidential and I request that the information supplied is used solely by you and is not shared.

Please now fill in the information and I will contact you with further steps soon.

Email *

First & Last Name *

First & Last Name

Date of Birth *

Date of Birth

Gender * Gender

Gender

How Did You Hear About Me *

How Did You Hear About Me

Height * Height

Height

Current Body Weight *

Current Body Weight

Desired Body Weight *

Desired Body Weight

Daily Activity *

Daily Activity

Sedentary - Sitting at the computer most of the day, or sitting at a desk.

Lightly active - Light industrial work, sales or office work that comprises light activities.

Moderately active - On your feet comprised of moderate activity (ex: Cleaning, kitchen staff, or delivering mail on foot or by bicycle.)

Very active - Heavy industrial work (iron, coal, etc.), construction work, brick mason, or farming.

Workout Activity

*

Workout Activity

Sedentary - No working out

Lightly active - Low intensity aerobics

Moderately active - High intensity aerobics or weight training

Very active - Weights 3+/week + aerobics

Extremely active - 2+ hrs/day and athletes

We Need To Contact You

Primary Email Address *

Primary Cell Phone Number With Area Code *

What is your preferred method of contact *

Email

Phone

Text

If none of the above options suits you, please write here how do you prefer me to contact you.

In general, what are your goals? Write down ALL the goals from above that apply. * In general, what are your goals? Write down ALL the goals from above that apply.

In general, what are your goals? Write down ALL the goals from above that apply.

Please list all of your concerns about your health, eating habits, fitness and/or body * Please list all of your concerns about your health, eating habits, fitness and/or body

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

What makes it/them important/urgent to you? *

What makes it/them important/urgent to you?

What Are You Hoping For?

What do you expect from me as your health/nutrition coach? *

What should your coach do if you fall behind on the plan to help reach your goals? *

What are you prepared to do to work toward your goals? *

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 them now) *

How would you like your habits, your health, your eating and/or your body to be different? Be specific. *

Have you already made changes to your habits, your health, your eating and/or your body recently? If so, what has changed? *

If you were to consider making further changes to your habits, your health, your eating and/or your body, what might those changes be? *

Until now, what has blocked you or held you back from changing this/these? *

Right now, how would you rank your overall eating/nutrition habits? (where 1=Horrible and 10=Awesome) *

Why? *

Are you regularly active in sports and/or exercise? *

If so, how many hours per week? *

5 Hours or Less

5-9 Hours

10-14 Hours

15 Hours or More

What types of sports/exercise do you typically do? *

Describe these others forms of movement/activities *

Lifestyle & Environment

Who lives with you? Write down ALL that apply. (Spouse or partner; Child(ren); Roommate(s); Other family (e.g. parent, grandparent, sibling, etc.); Pet(s)) *

Do you have children? *

If yes, how many and what are their ages? *

Who does most of the grocery shopping in your household? Write down ALL that apply. (Me; Spouse/partner; Roommate(s); Child(ren); Other family member) *

Who does most of the COOKING in your household? Write down ALL that apply. (Me; Spouse/partner Roommate(s); Child(ren); Other family member) *

Who decides on most of the menus/meal types in your household? Write down ALL that apply. (Me; Spouse/partner; Roommate(s); Child(ren); Other family member) *

Right now, how much do the people and things around you support your health, fitness and/or behavior change? (where 1=Not at all and 10=Completely) *

Health

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

If yes, please list. *

Right now, do you have any specific health concerns such as illnesses, pain, and/or injuries? *

If yes, please list. *

Are you currently taking any prescription or over the counter medicines? *

If yes, please list dosage, strength and frequency *

On a scale of 1-10, how do you rank your health right now? (where 1=Horrible and 10=Awesome) *

Why? *

Time Management

Think about your weekly commitments and answer the following... In an average week, how many hours do you spend...

In paid employment *

5 Hours or Less

6-10

11-15

16-20

21-25

26-30

31-35

36-40

More than 40

At school or doing school work *

5 Hours or Less

6-10

11-15

16-20

21-25

26-30

31-35

36-40

More than 40

Traveling and/or commuting *

5 or less

6 - 10

11 - 15

16 - 20

21 - 25

26 - 30

31 - 35

36 - 40

More than 40

Taking Care of Others *

5 Hours or Less

6-10

11-15

16-20

21-25

26-30

31-35

36-40

More than 40

Doing unpaid work (e.g. housework/errands) *

5 Hours or Less

6-10

11-15

16-20

21-25

26-30

31-35

36-40

More than 40

Volunteering

5 or less

6-10

11-15

16-20

21-25

26-30

31-35

36-40

More than 40

Adding up all hours above, how many total hours per week do you spend doing ALL these activities? *

Do you maintain a calendar to manage your appointments and daily/weekly tasks (digital or print)? *

On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness? (where 1=My life is chaotic and 10=My life is perfectly calm and relaxed) *

Stress

Stress and Recovery

How Do You Cope?

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? (whew 1=No Stress and 10=Extreme Stress) *

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

4 or hours or less

5

6

7

8

9

10 hours or more

Do you typically have trouble falling asleep? *

Do you have a consistent bed/wake time? *

Do you eat within 2 hours of bed time? *

Yes

No

Sometimes

Do you drink alcohol before bed? *

Yes

No

Sometimes

Do you wake up rested and energized in the morning? *

Yes

No

Sometimes

How do you normally cope with your stress? *

How Ready Are You

Ready Or Not

How READY are you to change behaviors and habits that keep you from your goals? *

How Willing Are You?

How WILLING are you to change behaviors and habits that keep you from your goals? *

It's Up To You!

How ABLE are you to change behaviors and habits that keep you from your goals? *

You Have The Power (It's In You)

Please explain any hesitation to being READY, WILLING or ABLE *

Additional Coaching Available - Paid Sessions

Do You Require One On One Paid Coaching Sessions

If So In What Area's *

Disclaimer

Health/wellness and/or nutrition coaching is not intended to diagnose, treat, prevent or cure any disease or condition. It should not be a substitute for the advice, treatment and/or diagnosis of a qualified licensed professional. Certified Health or Nutrition coaches may not make any medical diagnosis, claims, or substitute for your personal physician's care. As your health/wellness/nutrition coach, I do not provide a second opinion or in any way attempt to alter the treatment plans or therapeutic goals of your personal physician or healthcare team. It is my role to partner with you to provide ongoing support, resources and accountability as you create an action plan to meet and maintain your health goals.

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