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Sample Client Information Sheet

691 Words3 Pages

Client Information Sheet All personal information is confidential and treated appropriately. Client Name Address City State Zip Phone E-Mail Cell Date of birth: __________ Age:_______ Marital status Employment Information: Occupation How long? Employer name Reason for engaging a Coach ___________________________________________________________ ___________________________________________________________________________________ Referred By: What are your main personal health concerns, in order of importance? 1.__________________________________________________________________________________ 2.__________________________________________________________________________________ …show more content…

Once we start our coaching relationship we will track what you are eating in a food journal 1. How many meals and snacks do you eat each day? Meals _____ Snacks _____ 2. How many times a week do you eat the following meals away from home? Breakfast _____ Lunch _____ Dinner _____ 3. What types of eating place do you frequently visit (Check all that apply) Fast- Food _____ Diner/cafeteria _____ Restaurant _____ Other

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