Are you satisfied with your current state of health?   YES     NO     SOMEWHAT

If not, what would you like to change?   WEIGHT     SLEEP     SYMPTOMS     MOOD

Which of these have you tried in the past?  DIET     GYM     SUPPLEMENTS     MEDICATION     THERAPY

Have you ever worked with a health coach or therapist?  YES    NO

How satisfied were you with the results?  VERY     SOMEWHAT     NOT SO MUCH

Do you prefer to work on your health goals independently or as part of a group?   ALONE     GROUP     BOTH     NOT SURE

What would appeal most to you about working with a health coach? COMPASSION  ACCOUNTABILITY  INFORMATION  OTHER


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