Health Intake Forms - evolvetofitness.com

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– Step 1 of 12

Name *

First

Last

Email *

Phone *

Your main motive for this change is for your own reasons and not because other people think you should. *

True
False

You have more than one reason why you believe you want to change your behavior (e.g., lose weight) which may positively impact your overall quality of life. *

True
False

You do not believe you are capable of participating in the activity and tasks that are needed in order for you to make successful changes. *

True
False

You are unwilling to make the commitment of time and effort needed to change your current behavior as your life is already quite stressful. *

True
False

You will accept the fact that sustained success may be a slow and challenging process, yet you will continue your efforts despite the disappointments. *

True
False

You are not prepared to be patient with yourself and will most likely give in or quit when you encounter obstacles, backlashes or barriers. *

True
False

You do not have the support for this change from friends, family or loved ones. *

True
False

You have never before tried to change this behavior or a behavior similar to this one. *

True
False

You accept the reality that your ultimate success requires sustainable behaviors as opposed to temporary changes regardless of your rates of success. *

True
False

You recognize that a structured and disciplined approach to making and sustaining healthier behaviors will be needed for indefinite periods of time to help achieve the goal(s) you desire. *

True
False

Perceived Stress Scale *

	Never	Almost Never	Sometimes	Often	Very Often
In the last month, how often have you been upset because of something that happened unexpectedly?	NeverIn the last month, how often have you been upset because of something that happened unexpectedly? Never	Almost NeverIn the last month, how often have you been upset because of something that happened unexpectedly? Almost Never	SometimesIn the last month, how often have you been upset because of something that happened unexpectedly? Sometimes	OftenIn the last month, how often have you been upset because of something that happened unexpectedly? Often	Very OftenIn the last month, how often have you been upset because of something that happened unexpectedly? Very Often
In the last month, how often have you felt tha t you were unable to control the important things in your life?	NeverIn the last month, how often have you felt tha t you were unable to control the important things in your life? Never	Almost NeverIn the last month, how often have you felt tha t you were unable to control the important things in your life? Almost Never	SometimesIn the last month, how often have you felt tha t you were unable to control the important things in your life? Sometimes	OftenIn the last month, how often have you felt tha t you were unable to control the important things in your life? Often	Very OftenIn the last month, how often have you felt tha t you were unable to control the important things in your life? Very Often
In the last month, how often have you felt nervous and “stressed”?	NeverIn the last month, how often have you felt nervous and “stressed”? Never	Almost NeverIn the last month, how often have you felt nervous and “stressed”? Almost Never	SometimesIn the last month, how often have you felt nervous and “stressed”? Sometimes	OftenIn the last month, how often have you felt nervous and “stressed”? Often	Very OftenIn the last month, how often have you felt nervous and “stressed”? Very Often
In the last month, how often have you felt confident about your ability to handle your personal problems?	NeverIn the last month, how often have you felt confident about your ability to handle your personal problems? Never	Almost NeverIn the last month, how often have you felt confident about your ability to handle your personal problems? Almost Never	SometimesIn the last month, how often have you felt confident about your ability to handle your personal problems? Sometimes	OftenIn the last month, how often have you felt confident about your ability to handle your personal problems? Often	Very OftenIn the last month, how often have you felt confident about your ability to handle your personal problems? Very Often
In the last month, how often have you felt that things were going your way?	NeverIn the last month, how often have you felt that things were going your way? Never	Almost NeverIn the last month, how often have you felt that things were going your way? Almost Never	SometimesIn the last month, how often have you felt that things were going your way? Sometimes	OftenIn the last month, how often have you felt that things were going your way? Often	Very OftenIn the last month, how often have you felt that things were going your way? Very Often
In the last month, how often have you found that you could not cope with all the things that you had to do?	NeverIn the last month, how often have you found that you could not cope with all the things that you had to do? Never	Almost NeverIn the last month, how often have you found that you could not cope with all the things that you had to do? Almost Never	SometimesIn the last month, how often have you found that you could not cope with all the things that you had to do? Sometimes	OftenIn the last month, how often have you found that you could not cope with all the things that you had to do? Often	Very OftenIn the last month, how often have you found that you could not cope with all the things that you had to do? Very Often
In the last month, how often have you been able to control irritations in your life?	NeverIn the last month, how often have you been able to control irritations in your life? Never	Almost NeverIn the last month, how often have you been able to control irritations in your life? Almost Never	SometimesIn the last month, how often have you been able to control irritations in your life? Sometimes	OftenIn the last month, how often have you been able to control irritations in your life? Often	Very OftenIn the last month, how often have you been able to control irritations in your life? Very Often
In the last month, how often have you felt that you were on top of things?	NeverIn the last month, how often have you felt that you were on top of things? Never	Almost NeverIn the last month, how often have you felt that you were on top of things? Almost Never	SometimesIn the last month, how often have you felt that you were on top of things? Sometimes	OftenIn the last month, how often have you felt that you were on top of things? Often	Very OftenIn the last month, how often have you felt that you were on top of things? Very Often
In the last month, how often have you been angered because of things that were outside of your control?	NeverIn the last month, how often have you been angered because of things that were outside of your control? Never	Almost NeverIn the last month, how often have you been angered because of things that were outside of your control? Almost Never	SometimesIn the last month, how often have you been angered because of things that were outside of your control? Sometimes	OftenIn the last month, how often have you been angered because of things that were outside of your control? Often	Very OftenIn the last month, how often have you been angered because of things that were outside of your control? Very Often
In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?	NeverIn the last month, how often have you felt difficulties were piling up so high that you could not overcome them? Never	Almost NeverIn the last month, how often have you felt difficulties were piling up so high that you could not overcome them? Almost Never	SometimesIn the last month, how often have you felt difficulties were piling up so high that you could not overcome them? Sometimes	OftenIn the last month, how often have you felt difficulties were piling up so high that you could not overcome them? Often	Very OftenIn the last month, how often have you felt difficulties were piling up so high that you could not overcome them? Very Often

The questions in this scale ask you about your feelings and thoughts during the last month. In each case, you will be asked to indicate by circling how often you felt or thought a certain way.

Your Action Plan

Most likely you’ve done some coaching goal planning in the past. This time I want you to make your plan by answering the following questions thoughtfully and intentionally. Be specific, please. (One-liners won’t do.)

Please list your motivation(s) for choosing to complete health coaching and the reasons you want to make a positive change in and for your health *

On a scale of 1 to 10 how motivated and willing are you to change

Selected Value: 0

What obstacles have kept you from making positive health changes in the past *

What are you willing to do in order to remove these obstacles? *

List your top 3 physical health goals *

Example: Reduce blood pressure so my doctor discontinues medication

List your top 3 spiritual health goals *

Example: Grow in kindness toward myself and others

What are you hoping to learn from this action plan? *

LIFE ASSESSMENT

Is anything keeping you from being the most authentic you? *

What is holding you back? *

What do you love and celebrate about yourself? *

What is missing in your life? *

Are you in a romantic relationship? If so, what is the best part about that relationship? What is the most challenging? *

Are you fulfilled in your work? *

How do you express yourself creatively? *

What is the dream inside of you dying to come out? *

Are you financially healthy or stressed? *

What rules do you follow that you wish you could break *

Is there an event in your life that you wish you could break? *

Do you have a friend or group of friends who you feel safe to be fully known by? *

When you think about a God who loves you, what comes to mind? *

Is there anyone you need to forgive? *

What do you think might lie at the root of your health challenges? *

Have you ever been involved with witchcraft of the cult? *

What does your body need to heal? *

What would it take to live a life your body would love? *

HEALTH ASSESSMENT EXERCISE HABITS

In the past 6 months, how often have you engaged in physical activity? *

Always – 7 days a week Regularly – 3 to 4x a week Semi regularly – 1-2 x a week Sporadically – 1-2 x a month

Please explain your current exercise regime or activities performed in the past: *

Please list any cardiovascular activities that you enjoy: *

Please list any strength training exercises that you enjoy: *

What are your personal barriers for exercising or sticking to a program? *

How much time do you plan on spending on your workout program? *

Min/Day Day/Week

WELLNESS GOALS

Why have you decided to begin or improve your exercise/ wellness program? *

Specifically describe what you would like to accomplish in your sessions. *

Specifically describe what you would like to accomplish through your fitness/wellness program during the next: *

1 Month 6 Months 1 Year

List your top 3 physical health goals? *

Example: reduce blood pressure so my doctor discontinues medications

List your top 3 spiritual goals? *

Example: Grow in kindness toward myself and others

What obstacles have kept you from making positive health changes in the past? *

What are you willing to do in order to remove these obstacles? *

PERSONAL HISTORY

In order to design a safe and effective coaching program, it is important that you complete the following Health History. It is crucial that you answer all the questions honestly and to the best of your ability. Please be advised that all information is kept strictly confidential.

Has your doctor ever told you that you have heart problems? *

Has your doctor ever told you that you have high blood pressure? *

Have you ever had stroke or heart attack? *

Have you ever had pain in your chest that concerned you? *

Do you ever feel faint or have dizzy spells? *

Have you had surgery in the last six months? *

Check the appropriate condition(s) that apply to you below:

Diabetes
Asthma
Heart Condition
Epilepsy
Pregnancy
Blood Pressure Concerns
High Cholesterol
Osteoporosis

Have you injured or have chronic pain in the following areas?

Neck
Elbows
Wrists
Upper Back
Knees
Lower Back
Shoulders
Hips
Feet

If yes, please explain:

Please list any prescribed medications with dosages : *

Please list any supplements or over the counter medications with dosages :

Please write any known reactions to exercise your medication can have on you: *

Do you smoke? *

Do you drink alcohol? *

If so, how many drinks per week?

Are there any other reasons (health or personal) that may limit or prevent you from exercising? *

READINESS TO CHANGE QUESTIONNARIE

Are you looking to change a specific behavior? *

Are you willing to make this behavioral change a top priority? *

Have you tried to change this behavior before? *

Do you believe there are inherent risks/dangers associated with not making this behavioral change? *

Do you have support for making this change from family, friends and loved ones? *

Besides health reasons, do you have other reasons for wanting to change this behavior? *

Are you prepared to be patient with yourself if you encounter obstacles, barriers, and /or setbacks? *

Coaching Agreement

By electronically signing this Agreement, the Client affirms understanding and agreement to the terms below.

1. Coaching Relationship

Coaching is a collaborative, strengths-based, and forward-looking relationship. The Coach partners with the Client to support behavioral change and goal progression. The coaching agenda is developed together by the Client and Coach.

The Client acknowledges that coaching is not therapy, counseling, or consulting.

2. Confidentiality

The Coach agrees to keep all Client communications and shared information private and confidential, in accordance with applicable laws. Information will not be shared without the Client’s explicit consent, unless required to prevent serious harm to the Client or others.

3. Coaching Commitment

The Client acknowledges that meaningful change takes time and agrees to engage in a coaching relationship for a minimum duration of three (3) months.

4. Session Procedures

Sessions may be held:

In person
By phone
Through video conference
By email

The format will be determined based on the selected coaching package.

Session Policies:

Both parties will begin and end sessions on time.
If the Client is more than 15 minutes late, the session will be considered canceled, and the full fee will apply.
If the Coach is more than 15 minutes late, the Client will not be billed for the session.

Cancellation Policy:

The Client agrees to cancel or reschedule sessions at least 24 hours in advance.
Sessions canceled with less than 24 hours’ notice will be subject to a 50% cancellation fee.

5. Coaching Fees

Details of coaching packages and fees are provided in Schedule 1.

A 3-month minimum commitment is required.
If the Client wishes to terminate before the 3 months, 30 days’ notice must be provided to receive a refund for any unused sessions.
Payment is due on the 1st of each month, before coaching services begin.

Accepted payment methods include:

Check
Credit/Debit Card
Electronic Funds Transfer (EFT)

6. Client Authorization and Signature

By signing below, the Client confirms that they:

Have read and understood this Agreement in full
Agree to the terms and conditions as stated
Consent to participate in coaching under this Agreement

Name *

First

Last

Date *

Signature *

Clear Signature

Release of Liability Form

By electronically signing this agreement, the Client acknowledges and agrees to the following terms:

1. Voluntary Participation

I, [Client Name], acknowledge that I am voluntarily participating in health coaching services provided by Evolve to Fitness LLC.

I understand that these services may include physical activity, emotional growth challenges, and dietary or lifestyle recommendations, all of which carry inherent risks.

2. Assumption of Risk

In consideration of being permitted to participate, I accept full responsibility for any risks, injuries, or damages—known or unknown—that may result from my participation in the program.

3. Release of Liability

I hereby release, waive, discharge, and agree not to sue Evolve to Fitness LLC, its officers, employees, or agents for any and all claims, demands, actions, or causes of action relating to loss, damage, or injury (including death) that may be sustained by me or my property during participation in the services provided.

4. Medical Disclaimer & Responsibility

I affirm that I have consulted or will consult with a physician regarding my participation in this program.
I confirm that I am physically fit and have no medical condition that would prevent my full participation.
I understand that Evolve to Fitness LLC is not a licensed healthcare provider and does not diagnose, treat, or cure any medical conditions.
All information provided is for educational and informational purposes only, and should not be considered medical advice.

5. Acknowledgment & Electronic Signature

I confirm that I have read and understood this Liability Waiver and Release Form in its entirety.
I fully understand that I am waiving substantial legal rights, including my right to sue.
I acknowledge that I am signing this agreement freely and voluntarily and intend it to be a complete and unconditional release of liability to the fullest extent permitted by law.

Name *

First

Last

Date *

Date

Time

Signature *

Clear Signature