Initial Assessment & Triage Questionnaire 

Name *
Name
Tell me more about yourself.
Date Of Birth
Date Of Birth
Gender
Staying in touch
What do you want?
Goals
What do you expect?
What do you want to change?
If so, what?
If so, what?
Right now, how would you rank your overall eating / nutrition habits?
How many hours per week are you regularly active in sports and / or exercise?
Approximately how many hours a week do you do other types of physical activity?
(e.g., housework, walking to work or school, home repairs, moving around at work, gardening)
What’s around you?
Who lives with you?
Check all that apply.
Who does most of the grocery shopping in your household?
Check all that apply.
Who does most of the cooking in your household?
Check all that apply.
Who decides on most of the menus / meal types in your household?
Check all that apply.
Right now, how much do the people and things around you support health, fitness, and / or behaviour change?
What’s your health like?
Have you been diagnosed (currently or in the past) with any signicant medical condition(s) and / or injuries?
Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries?
Right now, are you taking any medications, either over-the-counter or prescription?
How would you rank your health right now?
How are you spending your time?
How often do you consume alcohol?
Do you feel your schedule, time use, and overall busy-ness is calm and relaxed?
How is your stress and recovery?
Think about all the activities you’re involved in (e.g., work, school, caregiving, housework, travel). Then assess as best you can:
Given all the demands of your life, what is your typical stress level on an average day?
On average, how many hours per night do you sleep?
How ready, willing, and able are you to change?
How READY are you to change your behaviors and habits?
How WILLING are you to change your behaviors and habits?
How ABLE are you to change your behaviors and habits?
DISCLAIMER *