Health Discovery Form

To work with Mindy please fill out the health questionnaire. Thank you!

Please fill in this form with as much detail as you feel comfortable sharing; this enables your coach to come into the Discovery Session knowing as much about you and your goals as possible, so your partnership can begin on the right foot.

Name

First Name

Last Name

Email Address

Phone Number

(###)

###

####

Age

1. Main Health Goals

Why are you reaching out to Health Coach Mindy today? What specific health, wellness, and lifestyle changes would you like to make? On a scale of 1-10, how important is it to you to make each of these desired changes? 1 = not very important 10 = non-negotiable

Desired Health Change

Desired Health Change and Importance (1-10)

Desired Health Change

Desired Health Change and Importance (1-10)

Desired Health Change

Desired Health Change and Importance (1-10)

Desired Health Change

Desired Health Change and Importance (1-10)

Desired Health Change

Desired Health Change and Importance (1-10)

2. How would your life be different if you were to achieve these health changes?

3. What have been your barriers in creating these health changes for yourself?

4. How do you feel a Health Coach will help you achieve your goals?

Coachability Self Assessment

On a scale of 1-10, rate how ready you are to enter a health coaching relationship right now. 1 = I am not ready 5= I think I’m ready 10 = I am 100% ready and excited!

1. I am open-minded about learning new ways of eating, moving, and living.

Rating 1-10

2. I can commit to changes that feel uncomfortable, unusual, or unconventional.

Rating 1-10

3. I will communicate and negotiate with my health coach as an equal partnership, and feel confident to ask for what I need.

Rating 1-10

4. I have a high level of self-awareness.

Rating 1-10

5. I will keep my word to my coach and to myself.

Rating 1-10

6. I understand that health coaching is an investment in myself, and I will not suffer about the financial cost.

Rating 1-10

“If someone wishes for good health, one must first ask oneself if he is ready to do away with the reasons for his illness. Only then is it possible to help him.”
- Hippocrates: The father of medicine