Health Coaching Client Intake Form Template [25 questions] | Practice

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Health Coaching Client Intake Form Template

Are you a health coach looking for an easy way for your clients to fill out an intake form?

Introducing the Health Coaching Client Intake Form Template! This comprehensive form template helps you to quickly and easily collect all the information you need from your clients to start their health coaching journey.

This template covers all the key areas you need to know about your clients, such as their medical history, their lifestyle and wellness goals, and their previous attempts to make lifestyle changes. You can easily customize the form to suit your specific needs, and ensure that your clients have an easy and straightforward way to provide the information you need.

The template also includes helpful questions to ensure that you get the relevant information that you need to best serve your clients. You can add optional questions as needed, or modify the existing questions to suit your particular client's needs.

By using this comprehensive intake form template, health coaches can easily collect all the information they need to start helping their clients reach their wellness goals.

Health Coaching Client Intake Form Template

Date of Birth
Gender
Address
Marital Status
Occupation
Emergency Contact Name
Emergency Contact Number
Do you have any health conditions? If yes, then please share them below:
Are you currently taking any medications and/or supplements? If yes, then please indicate the medication/supplement name and the purpose below:
On a scale of 1-5 how would you rate your level of satisfaction with your nutrition?
On a scale of 1-5 how would you rate your level of satisfaction with exercise/movement?
On a scale of 1-5 how would you rate your level of satisfaction with sleep?
On a scale of 1-5 how would you rate your level of satisfaction with stress management?
Are you currently receiving psychiatric care of any kind? If yes, please specify.
Do you have any allergies, sensitivities, or food intolerances? If yes, please explain.
Do you use or consume any of the following substances?
What are your expectations from this coaching relationship?
As your coach, what roles can I serve that are the most important to you? Check any you feel are important.
We all face obstacles to making change or reaching our goals. Which of these can you most relate to? Choose up to three choices.
Do you have a faith or spiritual beliefs that you are willing to share?
Do you live with other people? If so, please share some information
Is there anything else you would like me to know about you?
How did you hear about us?
Would you like to receive updates, helpful tips, and promos?
AGREEMENT/REMINDERS:

I understand that all information I entered in this form will be considered strictly confidential.

The data gathered from this form will only be used as a basis for the type of coaching the client will need.

I understand that in order to be successful, it is vital to follow the plan agreed by both the life coach and the client.

I understand that I will be working with a health and wellness coach and will not be treated for any medical or psychiatric conditions.

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