Onboarding

We’re excited to have you on board and look forward to helping you achieve your health and lifestyle goals. This comprehensive questionnaire covers various aspects of your life, including personal, medical, dietary, sleep, lifestyle, and your goals. By answering these questions honestly and thoroughly, you provide us with valuable insights into your current situation, habits, and preferences, which will enable us to create a personalized plan tailored to your needs and aspirations.

The questionnaire consists mostly of open-ended questions that allow you to provide detailed information about your experiences, thoughts, and concerns. Please take your time and be as specific as possible when answering these questions. We understand that some topics might be sensitive or personal, but rest assured that your responses will be treated with the utmost confidentiality and respect.

To begin, please fill out the form below. We recommend setting aside about 30-45 minutes to complete the questionnaire in a quiet and comfortable environment. After submitting the form, we will carefully review your responses and get in touch with you to discuss the next steps.

Thank you for choosing Be Well with M as your partner on this journey towards improved health and well-being. We can’t wait to get started and support you in achieving your goals!

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1Introduction

2Medical

3Dietary

4Sleep

5Lifestyle

6Goals

Name *

First

Last

Contact Phone *

Email *

Date of Birth

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Height

Weight

Do you have any medical conditions I should be aware of?

Are you taking any medications, vitamins or supplements? If so, please list.

Have you had any blood tests in the last 6 months?

Is your doctor aware that you are seeing a health and lifestyle coach?

What are your main health concerns and how long have you had them?

Have you taken a lot of antibiotics over the course of your life?

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Do you have any allergies?

Do you avoid any foods or food groups for personal, medical or religious reasons?

Who does most of the cooking in your home?

Do you like to cook?

What % of your meals per week are cooked from scratch?

Do you generally read food labels when grocery shopping?

Do you crave any food?

How would you describe your appetite?

Do you eat when you’re bored or stressed?

Do you have or have had foods that you view as bad foods and good foods?

Do you have any negative thoughts around food?

How many times do you eat per day, meals and snacks?

What time do you normally eat breakfast?

What time do you normally eat dinner?

What is your favorite take-out food?

If you had a chef in your kitchen every day – what would you really like to eat for breakfast, lunch and dinner?

How many bowel movements would be normal in a day for you?

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How many hours of sleep do you average most nights?

What time do you normally go to bed?

Do you have a hard time falling asleep?

Do you wake up in the middle of the night on a regular basis?

Do you snore? or breath through your nose or mouth while sleeping?

Do you wake up feeling refreshed?

Do you track your sleep?

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Do you engage in exercise or physical activity on a regular basis?

Do you enjoy a particular form of exercise?

Apart from formal exercise do you engage in regular movement throughout the day? For example, gardening, walking, and cleaning at home.

Is your job stationary or active?

Do you like your job? If yes, why? If no – what would you do if you could do or be anything you wanted to?

Do you smoke?

Do you drink alcohol?

Are you exposed to chemicals at work?

Are you aware of the many harmful environmental toxins in most household cleaning products, gardening supplies, beauty products, cookware, plastic ware etc? and are you working towards removing them?

How would you rate your current stress level?

Selected Value: 1

1 having no stress and 10 being extremely stressed

Do you find it hard to relax? Do you use any specific coping strategies that work well for you?

How much time off do you take in a week? How much time off do you take in a year?

Do you have any major life stressors or long-term stressful situations in your life right now or have had in the past?

How are your energy levels?

Selected Value: 1

1 having low levels and 10 being high energy

Describe any moods, anger or anxiety levels or fluctuations you have?

Do you have a supportive network of friends/partner and family?

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What are your goals? What are you hoping to achieve on this journey?

Why do you want to make changes?

What if anything has worked for you in the past?

What limiting beliefs do you have that are stopping you or getting in the way?

Please provide anything else that you feel may be insightful/helpful on this journey.

Checkboxes *

• I acknowledge that I have read, understand, and agree to the disclaimer

Health Coach Disclaimer

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