7Core Wellness Initial Intake Questionnaire

Please fill out this form with as much detail as possible.

There are 8 sections and it may take up to 10 minutes to complete.

Your answers are important so I can provide you with the best service to meet your needs.

Thank you for your time!
Jen

SECTION 1: General Information - Step 1 of 8

SECTION 1: General Information

Today's Date *

Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Preferred Method of Contact *

Call
Text
Email

Gender *

Female
Male
Other

Emergency Contact - Name *

Emergency Contact - Phone Number *

How did you hear about 7Core Wellness / Warrior Approach? Who can we thank?

SECTION 2: Wellness Questions

What are your top wellness goals? Any goals particular to nutrition, fitness, wellbeing, self-care, and/or health? Be as detailed as possible. *

What is your why? Why do you have each of these goals? *

What would be different in your life or how would you feel if you achieved these goals? *

What does your best future self look like 1 year from now? *

Do you have a timeline for achieving each of these goals? *

What are your 3 top values? *

What do you feel are your biggest obstacles related to reaching your goals? *

What is one change you can make now toward reaching these goals? *

SECTION 3: Nutrition Questions

What changes do you feel you need to make in your nutrition? *

Do you have dietary preferences? (i.e. vegan, vegetarian, paleo, etc.) *

Do you have any food allergies and/or sensitivities you are aware of? *

If answered "yes" to the question above, please share. *

What nutrition programs have you tried before?

Did you have any success with those programs? If so, please describe.

What do you feel are your biggest challenges in obtaining your nutrition/health goals? *

SECTION 4: Fitness Questions

Are you currently involved in a fitness routine? *

If "yes" to the question above, describe your weekly routine.

How long have you been doing this routine?

Are you seeing results from your current fitness routine? If so, what? If not, what results would you like to see?

What movements/exercises do you enjoy doing?

What movements/exercises do you not enjoy doing?

Do you partake in any recreational activities or hobbies? If yes, please give more details.

What training equipment do you have at home?

What do you feel are your biggest challenges in obtaining your fitness goals? *

SECTION 5: Medical PARQ

1. Has your doctor ever said you have a heart condition or you should only perform physical activity recommended by a doctor? *

2. Do you feel pain in your chest when you perform physical activity? *

3. In the past month, have you had chest pain when you were not performing any physical activity? *

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

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

6. Is your doctor currently prescribing any medication for your blood pressure or a heart condition? *

7. Do you know of any other reason why you should not engage in physical activity? *

Notice:

If you have answered "yes" to one or more of the above questions, you may be asked to consult with your physician or obtain clearance before starting physical activity.

Please input your initials below to confirm the above information is true and accurate. *

SECTION 6: Medical History

Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, high blood pressure, high cholesterol, diabetes, lung conditions, etc.? *

If "yes" to the question above, please explain. *

Have you ever had any injuries or surgeries? *

If "yes" to the question above, please explain when, cause, limitations, rehab, etc. *

Are you currently in pain anywhere in your body? *

If "yes" to the question above, please explain. Include location, acute or chronic, what makes it worse, what makes it better, etc. *

Are you currently taking any medications? *

If "yes" to the questions above, please list what is taken and reason. *

When was your last physical? *

Do you have any other medical issues I need to be aware of? *

SECTION 7: Lifestyle Questions

Occupation

What is your current occupation?

Does your occupation require extended periods of sitting?

Does your occupation require extended periods of repetitive movement?

If answered "yes" to the questions above, please explain.

Stress

On a scale of 1 (least) to 10 (most), how stressful would you say your day typically is?

Selected Value: 1

What helps you to manage stress?

Sleep

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

How would you describe the quality of your sleep?

Support

Reflecting on your closest circle (family/friends), do you have support for making the changes needed to reach your goals?

Please tell me about your support network.

Faith and/or Religious Beliefs

Do you have strong faith and/or religious beliefs?

Please tell me more about your faith and/or religious beliefs.

SECTION 8: Final Questions

Training/Coaching Experience

Have you ever worked with a trainer or coach before for fitness/nutrition/health?

If answered "yes" to the question above, what did you enjoy about working with him or her?

Is there something that you feel the trainer or coach could have done better?

What do you hope to gain by working with me? *

Commitment

On a scale of 1 (unimportant) to 10 (extremely important), how important is it for you to change right now?

Selected Value: 1

If you marked the question above an 8 or below, what would need to happen to raise your score a couple of points?

On a scale of 1 (not committed) to 10 (all in), how committed are you to making the changes needed to meet your fitness, nutrition, health, and/or wellness goals?

Selected Value: 1

If you marked the question above an 8 or below, what would need to happen to raise your score a couple of points?

Is there anything else you feel I need to know? *

7Core Wellness Initial Intake Questionnaire

Please fill out this form with as much detail as possible.

There are 8 sections and it may take up to 10 minutes to complete.

Your answers are important so I can provide you with the best service to meet your needs.

Thank you for your time!Jen

SECTION 1: General Information

SECTION 2: Wellness Questions

SECTION 3: Nutrition Questions

SECTION 4: Fitness Questions

SECTION 5: Medical PARQ

Notice:

SECTION 6: Medical History

SECTION 7: Lifestyle Questions

Occupation

Stress

Sleep

Support

Faith and/or Religious Beliefs

SECTION 8: Final Questions

Training/Coaching Experience

Commitment

Thank you for your time!
Jen