Simple Questionnaire To Get Started

Client Information

Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Preferred Pronouns(Required)

He/Him/His

She/Her/Hers

They/Them/Theirs

Other

Health History

Current Medications (Include Dosage and Frequency)

Allergies (Food, Medications, Environmental, etc.)

Current Health Conditions or Diagnoses

Previous Surgeries or Hospitalizations

Lifestyle & Habits

Current Diet (Briefly describe typical meals)

Physical Activity (Exercise routines, frequency, and duration)

Sleep Patterns (Hours of sleep per night)

Stressors in Your Life (Work, Family, etc.)

Smoking or Tobacco Use

Yes

Alcohol Consumption (Frequency and amount):

Recreational Drug Use (If applicable)

Other Wellness Practices (Meditation, Yoga, etc.)

Health & Wellness Goals

What are your primary health and wellness goals?

Are there any specific challenges or obstacles you're facing in achieving these goals?

What motivates you to make positive changes in your health and wellness?

Expectations and Preferences

What do you hope to achieve through nurse coaching?

Do you have any specific preferences for your coaching sessions (e.g., in-person, virtual, frequency)

Are there any topics or areas of focus you would like to prioritize during coaching sessions?

Additional Information

Is there any other information or context you believe is important for me to know as your nurse coach?

Consent

Consent(Required)

By submitting this questionnaire, you acknowledge that the information provided is accurate to the best of your knowledge. You understand that the coaching sessions are not a substitute for medical advice or treatment and that you should consult with a healthcare provider for specific medical concerns.

I agree and consent. Now let's do this!

Simple Questionnaire To Get Started

Client Information

Health History

Lifestyle & Habits

Health & Wellness Goals

Expectations and Preferences

Additional Information

Consent

Disclaimer

We do not provide medical advice or endorse any specific products or treatments. Reliance on any information provided on this website is solely at your own risk.

The content on this website may change without notice, and we do not guarantee the accuracy, completeness, or timeliness of the information provided.

initiativewellness.com and its authors are not liable for any losses, injuries, or damages arising from the use of the information provided on this website.

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