Name
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First Name
Last Name
Email
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For each of the following statements, please choose the statement that most applies.
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1. At a buffet I.....
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2. My philosophy regarding food is.....
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3. My ideal restaurant is .....
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4. When it comes to leftovers, I.....
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5. When I am given an unusual dish, I.....
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6. When shopping, I look for .....
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7. When the food at a restaurant is disappointing, I .....
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8. Regarding conversation at the table with friends, I .....
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9. I enjoy eating the same meal every lunchtime.....
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10. When it comes to dishing up food, I.....
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11. When it comes to ordering at a restaurant, I .....
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12. I enjoy the type of food that's.....
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13. Presentation of a dish is.....
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14. I enjoy entertaining.....
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15. When it comes to dieting, I .....
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16. If I have to choose a restaurant to go to with visiting colleagues, I.....
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17. When I shop, I.....
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18. I do yoga or would take it up because.....
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19. Competitive bodybuilding to me is.....
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20. I prefer.....
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21. I exercise because.....
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22. When it comes to winning, I.....
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23. In a team, I tend to focus more on.....
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24. I participate in group fitness activities because.....
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25. I prefer to exercise on my own because.....
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26. When I set myself an exercise goal, I.....
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27. I don't exercise because.....
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28. When I have an exercise plan I.....
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29. My home is.....
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30. In my appearance, I aim to look.....
I understand that this information I've provided may be used to create personalized wellness goals and may be discussed in further detail during Wellness Coaching sessions.
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I understand that upon submission of this form, no information will be shared outside the confines of the Wellness Coaching sessions and the Wellness Coaching team.
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*Unless permission is given by the client for purposes related to furthering his/her wellness goals or in the event that any information provided is a concern for safety.
