Builds wellness intake assessments with health history, goal setting, and lifestyle evaluation questionnaires.
Use this skill when you need to:
DO NOT use this skill for medical intake forms, clinical assessments, or diagnostic questionnaires. This is for wellness coaches, personal trainers, and health coaches operating within their scope of practice.
A WELLNESS ASSESSMENT IS NOT A MEDICAL EXAM — IT IS A TOOL TO UNDERSTAND WHERE YOUR CLIENT IS, WHERE THEY WANT TO GO, AND WHAT LIFESTYLE FACTORS WILL HELP OR HINDER THEIR PROGRESS.
| Input |
|---|
| What to Ask |
|---|
| Default |
|---|
| Service type | "What service will you provide — personal training, health coaching, nutrition coaching?" | Health coaching |
| Client population | "Who are your typical clients?" | Adults 30-55, general wellness |
| Scope of practice | "What are your credentials and what are you qualified to assess?" | No default — must be provided |
| Assessment depth | "How detailed — quick screening or comprehensive intake?" | Comprehensive intake |
| Follow-up assessments | "Will you reassess periodically?" | Yes — every 8-12 weeks |
GATE: Confirm scope of practice before designing the assessment. Only include sections you are qualified to evaluate.
## Client Information
Name: _______________
Date: _______________
Date of birth: _______________
Email: _______________
Phone: _______________
Emergency contact: _______________
Emergency phone: _______________
## Health History
**Current medical conditions (check all that apply):**
[ ] Heart disease or cardiovascular condition
[ ] High blood pressure
[ ] Diabetes (Type 1 / Type 2)
[ ] Asthma or respiratory condition
[ ] Joint or bone issues (arthritis, osteoporosis)
[ ] Back pain or spinal conditions
[ ] Thyroid condition
[ ] Anxiety or depression
[ ] Autoimmune condition
[ ] None of the above
[ ] Other: _______________
**Current medications:**
_______________
**Allergies (food, medication, environmental):**
_______________
**Past surgeries or injuries:**
_______________
**Are you currently under a doctor's care for any condition?** Yes / No
If yes, has your doctor cleared you for [exercise / dietary changes]? Yes / No / Not yet
**For women: Are you pregnant or planning to become pregnant?** Yes / No / N/A
**Do you have any physical limitations that affect movement or exercise?**
_______________
## Current Lifestyle
**Sleep:**
- Average hours per night: ___
- Sleep quality (1-5, 5 = excellent): ___
- Do you have trouble falling or staying asleep? Yes / No
**Stress:**
- Current stress level (1-10, 10 = extremely stressed): ___
- Top 3 sources of stress: _______________
- How do you currently manage stress? _______________
**Nutrition (typical day):**
- Breakfast: _______________
- Lunch: _______________
- Dinner: _______________
- Snacks: _______________
- Water intake (glasses per day): ___
- Alcohol (drinks per week): ___
- Caffeine (cups per day): ___
**Physical Activity:**
- Current exercise frequency: ___ days/week
- Types of exercise: _______________
- Activity level at work: Sedentary / Lightly active / Active / Very active
**Habits:**
- Do you smoke? Yes / No / Former
- Screen time (hours per day outside of work): ___
## Your Goals
**Primary goal:**
_______________
**Why is this goal important to you right now?**
_______________
**What have you tried before to achieve this goal?**
_______________
**What worked? What didn't?**
_______________
**On a scale of 1-10, how ready are you to make changes?** ___
**On a scale of 1-10, how confident are you that you can succeed?** ___
**What is the biggest obstacle you anticipate?**
_______________
**How will you know you have succeeded? What does success look and feel like?**
_______________
**Timeline: When do you want to achieve this goal?**
_______________
## Wellness Assessment Summary — [Client Name]
**Date:** [Date]
**Assessed by:** [Your name]
### Key Findings
**Health considerations:**
- [Any conditions or medications that affect programming]
- [Referral needed? Yes/No — to whom]
**Lifestyle strengths:**
- [What they are already doing well]
**Lifestyle areas for improvement:**
- [Sleep, stress, nutrition, or activity gaps]
**Goal alignment:**
- Primary goal: [Goal]
- Readiness level: [X/10]
- Confidence level: [X/10]
- Timeline: [Stated timeline — realistic? Yes/No]
### Recommended Focus Areas (Priority Order)
1. [Focus area 1] — [Why and initial action step]
2. [Focus area 2] — [Why and initial action step]
3. [Focus area 3] — [Why and initial action step]
### Referrals Needed
- [ ] Medical clearance from physician
- [ ] Registered dietitian for [specific concern]
- [ ] Mental health professional for [specific concern]
- [ ] Physical therapist for [specific concern]
- [X] None needed at this time
Schedule reassessments at regular intervals:
| Format | Best For |
|---|---|
| Paper form | In-person consultations |
| Google Form | Remote clients, automated collection |
| PDF fillable form | Email-based intake |
| Practice management software | Integrated client management (Practice Better, TrueCoach) |