HC - Questionnaire

Contact Details

* Indicates required field

Name *

First

Last

Date of birth *

Email *

Contact number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency contact name *

Emergency contact number *

Medical Information

What is your primary health concern (this may be either physical or mental)? *

What have you done to work on this in the past? *

What (if anything) has proven effective? *

What is this health concern costing you? (energy, happiness, sleep, mood, money, relationships, confidence) *

If you're currently taking any medication, please specify what it is and what it is for *

Lifestyle

Do you drink alcohol on a regular basis? *

Yes No

Do you smoke? *

Yes No

Average hours sleep per night *

Rate your average daily energy levels *

What are 3 things you're grateful for or love about your life? *

Rate your average daily stress levels *

Goals

What would you like to be experiencing 30 days from now? *

What would you like to be experiencing 90 days from now? *

How important is it for you to achieve this 90 day goal? *

How confident are you that you can achieve this 90 day goal? *

What is motivating you to achieve this 90 day goal? *

What obstacles may prevent you from achieving this 90 day goal? *

Disclaimer

You (sometimes referred to herein as “Client”) understand that the information received from me (sometimes referred to herein as “Coach”) in connection with the Program or otherwise should not be seen as medical, nursing or nutrition advice and is certainly not meant to take the place of your seeing licensed health professionals, including your doctor.

You understand and agree that (i) I am not providing health care, medical or nutrition therapy services and will not diagnose, treat or cure in any manner whatsoever, any disease, condition or other physical or mental ailment of the human body, (ii) I am not acting in the capacity of a doctor, licensed dietician-nutritionist, massage therapist, psychologist or other licensed or registered professional, and (iii) you have chosen to work with me and participate in the Program voluntarily.

As your Coach, I encourage you to maintain a relationship with your primary care physician or doctor. In the event that you do not have one and/or do not have routine physicals, I encourage you to do so. Do not discontinue or change any treatment plan that you may be on as a result of our sessions without discussing the change with your doctor.

You acknowledge and take full responsibility for your life and wellbeing, as well as the lives and wellbeing of your family (where applicable), and all decisions made during and after the Program. In furtherance and not in limitation of the foregoing, you hereby and forever waive, release and discharge me, my heirs, executors, administrators, assigns, officers, agents, employees, representatives, executors and all others acting on their behalf (the “Released Parties”) from any and all claims or liabilities for injuries or damages to your person and/or property or that of your family (where applicable), including those caused by negligent act or omission of any of those mentioned or others acting on their behalf, arising out of or connected with your participation in the Program or in connection with services provided by me or the Released Parties.

I have answered this form truthfully and agree to the terms above *

I agree

Submit

Kudos Health​Coaching​Questionnaire

Contact Details

Medical Information

Lifestyle

Goals

Disclaimer

Kudos Health
Coaching
Questionnaire