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Life & Health Coaching Questionnaire
Name
*
Email
*
Phone
*
What are your primary reasons for seeking a coach?
would like someone to keep me accountable of my progress
would like to define new or re-define existing goal
other (please specify)
Primary Reason: Other
Have you gone through the IOP?
Yes
I would like to make changes on the following areas of my life:
Physical activity
Nutrition
Weight Management
Smoking cessation
Sleep hygiene
Stress management
Spiritual growth
Other (please specify)
Other
On a scale from one to 10 (being 10 excellent), how would you rate your overall wellbeing?
In what way is this impairing your life?
In order of importance, what areas of your health would you like to start focusing more on?
Physical
Extremely Important
Very Important
Important
OK
Mental / Emotional
Extremely Important
Very Important
Important
OK
Social
Extremely Important
Very Important
Important
OK
Spiritual
Extremely Important
Very Important
Important
OK
Name
This field is for validation purposes and should be left unchanged.
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