SHC-Swiss Health Coaching
Phone: (+852)-55010375
email: swisshealthcoaching(at)bluewin.ch
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First Appointment
BMI Calculator
Client Information Questionnaire
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How did you hear about this site?
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Internet Search
Advertisement
Friend
Other
If Other please specify:
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Do you frequently have pains in your chest when you perform physical activity?
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Yes
No
Have you had chest pain when you were not doing physical activity?
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Yes
No
Do you lose your balance due to dizziness or do you ever lose consciousness?
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Option 1
Option 2
Option 3
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)?
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Yes
No
Choose One
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Option 1
Option 2
Option 3
Have you had a recent surgery?
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Yes
No
If you have marked YES to any of the above, please elaborate below:
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Do you take any medications, either prescription or non-prescription, on a regular basis?
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Yes
No
What is the medication for?
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How does this medication affect your ability to exercise or achieve your fitness goals?
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Lifestyle Related Questions:
1. Do you smoke?
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Yes
No
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2. Do you drink alcohol?
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Yes
No
If yes, how many glasses per week?
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Choose One
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Option 1
Option 2
Option 3
Choose One
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Option 1
Option 2
Option 3
How many hours do you regularly sleep at night?
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4. Describe your job
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Sedentary
Active
Physically Demanding
5. Does your job require travel?
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Yes
No
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6. On a scale of 1-10, how would you rate your stress level (1=very low 10=very high)?
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Comment
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8. Is any one in your family overweight?
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Mother
Father
Siblings
Grandparent
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9. Were you overweight as a child?
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Yes
No
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Fitness History
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2. Have you been exercising consistently for the past 3 months?
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Yes
No
3. When did you first start thinking about getting in shape?
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4. What if anything stopped you in the past?
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Nutrition Related Questions
1) On a scale of 1-10, how would you rate your Nutrition (1=very poor 10=excellent)?
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2) How many times a day do you usually eat (including snacks)?
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Choose One
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Option 1
Option 2
Option 3
5) Do you eat late at night?
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Sometimes
Often
Never
4) Do you eat breakfast?
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Yes
No
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7) How many glasses of water do you consume daily?
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8) Do you feel drops in your energy levels throughout the day?
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Yes
No
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9) Do you know how many calories you eat per day?
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Yes
No
If yes, how many?
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10) Are you currently or have you ever taken a multivitamin or any other food supplements?
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Yes
No
If yes, please list the supplements:
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11) At work or school, do you usually:
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Eat Out
Bring Food
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Choose One
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Option 1
Option 2
Option 3
14) Do you do your own cooking?
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Yes
No
15) Besides hunger, what other reason(s) do you eat?
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Boredom
Social
Stressed
Tired
Depressed
Happy
Nervous
16) Do you eat past the point of fullness?
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Often
Sometimes
Never
17) Do you eat foods high in fat and sugar?
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Often
Sometimes
Never
18) List 3 areas of your Nutrition you would like to improve:
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Exercise Related Questions:
Skip to next section if you are presently inactive.
1) How often do you take part in physical exercise?
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1 - 2x/week
3 - 4x/week
5 - 7x/week
2) If your participation is lower than you would like it to be, what are the reasons?
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Lack of Interest, Illness/Injury
Lack of Time
Other
Other reasons:
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4) What activities are you presently involved in?
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Cardio/Fitness
Strength Training
Stretching
Comment
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