Client Questionnaire

Legal first name

Last name

Phone

Date of birth (YYYY-MM-DD)

Gender

State of Residence

What are your top 3 health concerns?

What approaches have you already tried?

What changes do you know you should make but haven’t?

What are your primary obstacles to making changes?

On a scale of 1 – 10, how committed are you to making changes that will support your health goals?

What is one change you commit to making this week that will move you closer to supporting your health?