Discover a Healthier, Fitter, More Energised You.

HnW CC I Form

Health & Wellness Coaching Client Intake Form

🌿 Personal Information

* Full Name: ___________

* Age: ___________

* Gender: ___________

* Contact Number: ___________

* Email Address: ___________

🌿 Lifestyle & Habits

1. Describe your typical daily routine:  ________________________

2. How many hours of sleep do you get on average per night?

   ___________

3. Do you smoke or consume alcohol? (Yes / No) If yes, frequency:

   ___________

4. How would you rate your stress level (1–10)?

   ___________

5. How many days per week do you exercise?

   ___________ Type of Exercise: ___________

🌿 Nutrition Habits

* Do you follow a specific diet (e.g., vegetarian, keto)?

   ___________

* How many meals & snacks do you typically consume in a day?

   ___________

* Any food allergies or intolerances?

   ___________

🌿 Medical History

* Do you have any diagnosed medical conditions (e.g., diabetes, hypertension)? If yes, please specify:   ________________________

* Are you taking any prescribed medication? If yes, please list:   ________________________

* Have you experienced any major health challenges in the past year? Please describe:   ________________________

🌿 Health Goals

1. ________________________

2. ________________________

3. ________________________

🌿 Red Flags (Mandatory to Fill)

* Do you experience any of the following symptoms frequently?

  - Chest pain / Shortness of breath / Unexplained weight loss / Extreme fatigue / Severe digestive issues / Mental health struggles (Yes / No)

  If Yes, please explain: ________________________

Signature & Date: ___________

Personalized Wellness Coaching Plan

🔸 Client Name: ___________

🔸 Date of Plan: ___________

🔸 Health Goals:

   1. ______________

   2. ______________

   3. ______________

✅ Nutrition Goals

* Eat 3 balanced meals + 1 healthy snack daily

* Increase water intake to at least 2 liters per day

* Reduce sugar and processed food consumption

✅ Physical Activity Plan

* 30 minutes of moderate exercise (e.g., brisk walking, yoga) 5 days/week

* Incorporate stretching exercises daily

✅ Stress Management

* Practice mindfulness meditation for 10 minutes daily

* Engage in a relaxing hobby 3 times per week

✅ Sleep Hygiene

* Maintain a consistent sleep schedule (7–8 hours/night)

* Avoid screens at least 1 hour before bedtime

✅ Tracking & Accountability

* Weekly progress check-ins via phone or message

* Use a simple habit tracker (e.g., notebook or app)

✅ Important Notes

⚠️ If you notice any unusual symptoms (chest pain, severe fatigue, etc.), please consult a medical professional immediately.

✔️ Remember: This plan supports lifestyle improvements and is not a substitute for medical care.

📅 Next Follow-up Date: ___________

✔️ Client Signature: ___________

✔️ Coach Signature: ___________

Copy, paste, fill up and send to whatsApp # 9687817443 for further guidance.