Health and Wellness Questionnaire

Thank you for taking the time to complete this questionnaire.

Your responses help us understand your health history, goals, and needs, allowing us to create a personalized plan to support you on your wellness journey.

First Name

Last Name

Phone *

Email *

Quiz Questions

Thank you for your interest in working with Nurse Coach Chat.

This questionnaire helps us better understand your health history, wellness goals, lifestyle habits, and coaching needs so we can create a realistic, personalized plan designed for sustainable long-term success.

What are your top 3 health goals right now?

Why are these goals important to you right now

If Other, please provide details

What worked well for you previously?

Do you currently work with any healthcare providers?

Yes

No

Do you have any food allergies or sensitivities?

How motivated do you currently feel about improving your health?

Do you have a support system?

Yes

No

Somewhat

Preferred Meeting Times

Morning

Afternoon

Evening

Are you comfortable attending virtual Zoom sessions or on the phone?

Virtual Zoom

Phone Call

What would success look like for you in the next 6–12 months?

Is there anything else you would like us to know?

Consent & Acknowledgment
By checking this box, I understand that coaching provided through Nurse Coach Chat is educational and supportive in nature and is not intended to diagnose, treat, or replace medical care from a licensed healthcare provider.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from Nurse Coach Chat at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

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