Online Health Coaching Intake Form (Holistic Telehealth)
I. Personal Information
First Name
Last Name
Date of Birth
Gender
Email Address
Phone Number
Preferred Method of Communication
Time Zone
Emergency Contact Name
Emergency Contact Phone Number
Time Zone
Preferred Method of Communication
II. Health History
Do you have any diagnosed medical conditions?
If yes, please list them.
Are you currently taking any medications or supplements?
If yes, please list them.
Do you have any allergies or food intolerances?
If yes, please specify.
Have you had any surgeries or hospitalizations in the past 5 years?
If yes, please describe.
Do you have a family history of chronic illnesses (e.g., diabetes, heart disease, cancer)?
If yes, please specify.
Are you currently under the care of a physician or other healthcare provider?
If yes, please provide their name and contact information.
III. Lifestyle Assessment
Diet and Nutrition
How would you describe your current diet?
Balanced
Vegetarian/Vegan
Low-carb/Keto
High-protein
Other (Please specify):
How many servings of fruits and vegetables do you typically eat per day?
0-1
2-3
4-5
6+
Do you have any specific dietary goals? (e.g., weight loss, improved digestion, managing a condition)
What challenges do you face with maintaining a healthy diet?
Physical Activity
How often do you engage in physical activity?
Never
1-2 times per week
3-4 times per week
5+ times per week
What types of exercise do you enjoy?
Walking
Yoga
Weightlifting
Swimming
Other (Please specify):
Do you have any physical limitations or injuries that affect your ability to exercise?
What are your fitness goals?
Build strength
Improve endurance
Lose weight
Other (Please specify):
Stress Management
How would you rate your stress levels on a scale of 1-10 (1 = low, 10 = high)?
What are your primary sources of stress?
Work
Relationships
Finances
Other (Please specify):
What strategies do you currently use to manage stress?
Meditation
Exercise
Hobbies
Other (Please specify):
Are you interested in learning new stress management techniques?
Sleep Habits
How many hours of sleep do you typically get per night?
Do you have trouble falling or staying asleep?
What is your bedtime routine like?
Social and Emotional Well-being
How would you describe your overall mood and emotional state?
Do you feel supported by friends and family?
Are there any relationships or social situations that negatively impact your well-being?
IV. Goals and Expectations
What are your primary health and wellness goals?
Lose weight
Reduce stress
Improve energy levels
Other (Please specify):
What motivates you to make lifestyle changes at this time?
What challenges or obstacles do you anticipate in achieving your goals?
How do you define success in this coaching program?
What is your preferred pace for making changes?
Slow and steady
Moderate
Fast and intensive
V. Goals and ExpectationsSuitability for Coaching
Have you worked with a health coach or similar professional before?
If yes, what was your experience like?
What are your expectations from this coaching program?
Are you willing to commit time and effort to make lifestyle changes?
If yes, how much time per week can you dedicate to this program?
Have you worked with a health coach or similar professional before?
Do you have any concerns about starting this program?
Are there any specific topics or areas you would like the coaching to focus on?
VI. Consent and Agreement
I understand that this coaching program is not a substitute for medical advice, diagnosis, or treatment.
I give permission for my health coach to contact my healthcare provider if necessary.
I agree to the terms and conditions of the coaching program.
Client Signature:
Client Intake Form Insights
Client Intake Form Insights
Please remove this client intake form insights section before publishing.
Section 1: Personal Information
Purpose:
- To establish basic contact details and demographic information.
- To ensure the coach can communicate effectively with the client and tailor sessions to their time zone.
Insights:
- Preferred communication methods help the coach understand how the client is most comfortable interacting (e.g., video calls for visual learners, text messaging for busy individuals).
- Emergency contact information ensures safety and preparedness in case of unforeseen circumstances.
Section 2: Health History
Purpose:
- To identify any medical conditions, medications, or allergies that may impact the coaching plan.
- To understand the client’s family history and current healthcare provider relationships.
Insights:
- Diagnosed conditions (e.g., diabetes, hypertension) or medications may require collaboration with the client’s healthcare provider.
- Allergies or intolerances (e.g., gluten, dairy) help tailor dietary recommendations.
- Family history provides context for potential genetic risks (e.g., heart disease, cancer).
- Knowing if the client is under a physician’s care ensures the coaching complements, rather than conflicts with, medical treatment.
Section 3: Lifestyle Assessment
Purpose:
- To evaluate the client’s current habits in key areas of wellness: diet, exercise, stress management, sleep, and emotional well-being.
- To identify areas of strength and opportunities for improvement.
Insights:
1. Diet and Nutrition:
- Current dietary patterns reveal whether the client’s eating habits align with their goals (e.g., weight loss, improved energy).
- Challenges (e.g., emotional eating, lack of time) help the coach design practical strategies.
2. Physical Activity:
- Frequency and type of exercise indicate the client’s current fitness level and preferences.
- Physical limitations or injuries guide the creation of safe, tailored exercise plans.
3. Stress Management:
- Stress levels and sources highlight areas where the client may need support (e.g., work-related stress, relationship issues).
- Current coping mechanisms (e.g., meditation, exercise) show what works and what might need improvement.
4. Sleep Habits:
- Sleep duration and quality provide insight into potential energy or mood issues.
- Bedtime routines can be optimized to improve sleep hygiene.
5. Social and Emotional Well-being:
- Mood and emotional state help the coach assess mental health needs.
- Support systems (or lack thereof) indicate whether the client may benefit from building stronger social connections.
Section 4: Goals and Expectations
Purpose:
- To clarify the client’s primary objectives and motivations for seeking coaching.
- To understand their readiness for change and preferred pace of progress.
Insights:
- Specific goals (e.g., weight loss, stress reduction) allow the coach to create a targeted action plan.
- Motivations (e.g., improving energy for family, managing a health condition) help the coach align the program with the client’s values.
- Anticipated challenges (e.g., time constraints, lack of motivation) enable the coach to proactively address barriers.
- Preferred pace (slow, moderate, fast) ensures the program aligns with the client’s comfort level and prevents overwhelm.
Section 5: Suitability for Coaching
Purpose:
- To assess the client’s expectations, past experiences, and commitment level.
- To determine if the coaching program is a good fit for their needs.
Insights:
- Past experiences with health coaching or similar programs reveal what the client found helpful or unhelpful.
- Expectations (e.g., accountability, education) help the coach tailor their approach.
- Commitment level (time and effort) indicates whether the client is ready to take actionable steps.
- Concerns or specific focus areas (e.g., stress management, meal planning) allow the coach to address these directly.
Section 6: Consent and Agreement
Purpose:
- To establish clear boundaries and responsibilities for both the client and coach.
- To ensure the client understands the scope of the coaching program.
Insights:
- Acknowledgment that coaching is not a substitute for medical care ensures the client seeks appropriate treatment for medical conditions.
- Permission to contact healthcare providers fosters collaboration and holistic care.
- Agreement to terms and conditions sets the foundation for a professional and respectful coaching relationship.
Key Benefits of the Form
1. Personalization:
- The form provides a detailed snapshot of the client’s health, lifestyle, and goals, enabling the coach to create a highly personalized plan.
2. Readiness Assessment:
- Questions about motivation, commitment, and expectations help determine if the client is prepared for the coaching process.
3. Safety and Collaboration:
- Health history and consent sections ensure the coaching program is safe and aligned with the client’s medical care.
4. Goal Clarity:
By identifying specific goals and challenges, the coach can focus on actionable, meaningful outcomes.
5. Building Trust:
The thoroughness of the form demonstrates the coach’s professionalism and commitment to understanding the client’s unique needs.
How Coaches Can Use This Form
- Initial Assessment: Use the form to identify areas of focus and create a baseline for progress tracking.
- Ongoing Reference: Revisit the form during coaching sessions to ensure goals and strategies remain aligned with the client’s needs.
- Progress Evaluation: Compare initial responses to later updates to measure growth and adjust the plan as needed.
By leveraging the insights from this intake form, health coaches can deliver a more effective, client-centered experience that fosters sustainable lifestyle changes and holistic well-being.
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