Health Coach Client Intake Form

Collect everything needed to open a coaching file: contacts, body metrics, availability, goals, allergies, medication, current conditions and stress habits. A booking field sets the first session and the client signs at the end. Made for wellness coaches taking on new clients.

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Page 1

Full name

Nombre

Apellido

Age

Gender

Female Male Non-binary Prefer not to say

Date of birth

Phone number

Email

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Occupation

Company name

Emergency contact person

Nombre

Apellido

Emergency contact phone number

Best time to call

Page 2

Blood type

Weight (kg)

Height (cm)

Body mass index (BMI)

Preferred time

First appointment booking

Date

Time

Page 3

Are you currently working with a therapist or coach?

Yes No

Is this your first time hiring a health coach?

This is my first time I have worked with one before

Why are you looking for a health coach?

What do you expect to get from the coaching sessions?

What are your goals and ambitions?

Do you have allergies? If so, list them here.

Are you taking medication? Give the name and what it is for.

Page 4

What do you do to manage stress?

Which relaxation techniques do you use?

What makes you happy?

What takes your happiness away?

Page 5

Consent and acknowledgement

Patient signature

Sign here

Date signed

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