Health Coach Intake Form

First Name

Last Name

Email

Cell Phone

Date of Birth

Occupation

Preffered Mode of Communication

Have you worked with a health coach in the past? If yes, when?

What are your top 3 specific goals with health coaching?

On a scale of 1-10, how would you rate your nutrition?

On a scale of 1-10, how would you rate your water intake?

Do you eat regular meals?

How would you describe your diet?

How often do you get movement? What type?

How do you manage stress?

Do you have any pain? Are you under the care of a physician for any medical condition? If yes, please describe:

Please describe any health challenges that you currently experience (major concerns as well as things like headaches, insomnia, etc.)

Please list any medications / vitamins / dietary supplements you currently take:

Check all that apply:

  • Acid Reflux / Belching
  • Alcoholism
  • Allergies
  • Anemia
  • Anorexia / Bullemia
  • Anxiety
  • Arteritis
  • Asthma
  • Back Pain
  • Bladder Issues
  • Blood Clot / Embolism
  • Cancer
  • Cerebral Hemorrhage/Stroke
  • Chest Pain
  • Chronic Fatigue
  • Chronic Pain
  • COPD
  • Currently Pregnant
  • Depression
  • Diabetes
  • Dizziness/Fainting
  • Drug Problem
  • Fibromyalgia
  • Headaches and Migraines
  • Hearing Loss
  • Heart Conditions
  • High Cholesterol
  • High/Low Blood Pressure
  • Hyperglycemia/Hypoglycemia
  • Hyperthyroid/Hypothyroid
  • Irritable Bowel Syndrome
  • Joint Replacement
  • Kidney Disease
  • Liver Disease
  • Multiple Sclerosis
  • Numbness/Tingling
  • Osteoporosis
  • Pins or Metal Implants
  • Prostate Problems
  • Seizures/Epilepsy/Convulsions
  • Sexual/Physical Abuse
  • Shortness of Breath
  • Smoking History
  • Sports Injuries
  • Trouble Sleeping
  • Unexplained Weight Loss/Gain
  • Vision Loss/Problems

Other Conditions:

24 Hour Cancellation Policy

I understand that if I must cancel a scheduled appointment or class, I will notify the Concierge Desk by calling 360-352-3400 24 hours in advance or I will be held responsible for payment. The instructor will work hard to stay on schedule. We respect and honor your time and we ask you to do the same.

I have read and understand the above

Informed Consent

Please sign to state that you read and understand the policy

I acknowledge that my participation in health and wellness coaching is expressly conditioned on my agreement to each of the terms of this document. I acknowledge and agree as follows: I understand that I should consult with a physician before I undertake any physical exercise program and health or wellness activity and program. I certify that I am in good health and sufficient physical condition to properly participate in health and wellness activities and programs. I acknowledge that the Valley’s health and wellness coach is not engaged in diagnosing or treating medical diseases or other medical conditions, nor do sessions serve as a substitute for medical diagnosis or treatment when such attention is needed. Because health and wellness coaching is contraindicated (should not be done) under certain medical conditions, I affirm that I have stated all my known medical conditions accurately and answered all questions honestly. I agree to keep the Valley’s Health and Wellness coach updated to any changes in my medical profile and understand that there shall be no liability on the health and wellness coach’s or the facility’s part should I forget to do so. I have read and fully understand this Acknowledgement and Release of Liability set forth above. I am 18 years old or older. I understand that my signed waiver will be retained in my client personnel file. This document is binding upon me and my heirs, children, wards, personal representatives and anyone else entitled to act on my behalf. By electronically signing the form below, “I Accept”.

Please check all consent and disclosure checkboxes.

Your form has been successfully submitted. Thank you!

Adult Signature:

Sign for Child: