Health Coaching Intake

Patient Name : Date :

Research shows that people who take time to recharge and restore are more creative, happier, and more successful. This questionnaire will help you identify the areas of your life that are well-tended and those that could use more time and attention. This is not meant to be a diagnostic assessment. Instead, it is a tool to help you see what you are doing to care for yourself. There are no right or wrong answers to these questions, and some of them may require a bit of thought. Take your time and answer each question to the best of your ability based on your self- care practices right now.

Instructions

For the following questions, please rank each item on a scale of 0 to 5, as follows :

0 = never 1 = rarely 2 = sometimes 3 = often 4 = regularly 5 = always

Physical Wellbeing — How often do you:

Eat a whole foods-based diet rich in colorful fruits and vegetables?
Drink enough water?
Exercise for more than 20 minutes?
Wake feeling refreshed from sleep?
Sleep at least 7 hours per night?
Make time to relax or nap?
Take time to breathe deeply throughout the day?
Engage in stress-reducing activities (excluding TV or screen time)?
Spend time in nature?
Feel nourished, healthy, and strong?

Physical Wellbeing Total:

Mental, Emotional, Spiritual Wellbeing — How often do you:

Make time to participate in things you enjoy?
Give and receive affection regularly?
Feel understood and valued by those who are close to you?
Feel gratitude on a daily basis?
Find meaning in life even during difficult times?
Take an interest in or find joy in the world around you?
Have hope that things will get better?
Express yourself creatively?
Treat yourself with kindness?
Remember to make your dreams and goals a priority?

Mental, Emotional, Spiritual Wellbeing Total:

Instructions

For the following questions, please rank each item on a scale of 0 to 5, as follows :

0 = never 1 = rarely 2 = sometimes 3 = often 4 = regularly 5 = always

Professional Life, Work, Career — How often do you:

Hold a work position in an area of your interest.
Work in a position that matches your professional goals.
Find a sense of meaning and enjoyment in your work.
Empathize and connect with customers, clients, and work colleagues.
Have confidence in your ability to address challenges in your professional life.
Feel supported at work or in your professional life.
Have someone you can rely on if you need help or guidance.
Set limits at work, whether it be with clients or tasks.
Disengage and leave pressures behind at the end of the day.
Take vacation or holiday breaks to allow for some downtime.

Professional Life, Work, Career Total:

Social Life, Family, Relationships — How often do you:

Have a dependable person who listens to you.
Have supportive family and friends close by.
Get enough social time with people who make you happy.
Participate in group activities with people who share a common interest.
Spend time with people who make you laugh.
Feel like your close relationships are loving and supportive.
Can say no comfortably.
Do something fun with family or friends at least once a week.
Feel like your personal life brings balance to your professional life.
Feel comfortable asking for help when you need it.

Social Life, Family, Relationships Total:

Score Interpretation and Next Steps

The higher your score in each section, the better you may be at taking time for self-care and wellness in each aspect of your life.Trying to improve your scores can help create more balance in your life. Consider items on which you scored 3 or lower. How can you modify your behavior to improve your self-care practices? What goals might you need to set to make these changes?

Wheel of Wellness

Look at each category and assess your wellness on a scale of 0 – poor (center) to 5 – excellent (outer ring). Do this instinctively,without too much hesitation. Next, think about what things would raise your rating in each category and use those ideas to set your goals.

Diet :
Exercise :
Hobbies :
Home :
Love :
Family :
Friends :
Spiritual :
Goals :
Work :
Finances :
Health :

GOALS

Please list any/all concerns about your physical health, mental health, eating habits, fitness and/or body, attitude, motivation,confidence etc. Please rate them in matter of importance.

Please explain why the top 3 are the most important.

In an ideal world, what are some goals (personally and/or professionally) you would like to accomplish over the next:

6 Months:

12 Months:

5 Years:

PURPOSE

Do you feel like your life has purpose?

What part of life brings you the most joy?

What brings the most disappointment/frustration?

Do you have a daily gratitude practice?

YES NO

What motiviates or inspires you to be the best version of yourself?

Understanding what is important to me
Understanding what motivates me
Understanding what is holding me back
Gaining insight into who I am as a person
Helping with goal setting
Identifying actionable next steps
Challenging me with difficult questions
Providing honest and direct feedback
Holding me accountable for my goals

HEALTH COACHING

Instructions

Physical Wellbeing — How often do you:

Mental, Emotional, Spiritual Wellbeing — How often do you:

Instructions

Professional Life, Work, Career — How often do you:

Score Interpretation and Next Steps

Wheel of Wellness

Wheel of Wellness

GOALS

PURPOSE

CHANGE

ENVIRONMENT

TIME

STRESS/RECOVERY

HOW IMPORTANT?On a scale of 1 to 10