Client Assessment Form 1: Personal Goals, Motivation and Stage of Readiness

CLIENT ASSESSMENT FORM 1
Personal Goals, Motivation and Stage of Readiness
My overall health goals are:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
My physical performance goals are:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
If I could change three things about my health and nutritional habits, they would be…
1. ______________________________________________________________________________
______________________________________________________________________________
2. ______________________________________________________________________________
______________________________________________________________________________
3. ______________________________________________________________________________
______________________________________________________________________________
4. ______________________________________________________________________________
______________________________________________________________________________
The biggest challenge(s) to reaching my nutrition goals is/ are:

_____________________________________________________________________________________
_____________________________________________________________________________________
In the past, I have tried the following techniques, diets, behaviours, etc. to reach my nutrition goals…
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you feel you’ve always had a weight problem? Yes No
If yes, around what age did you first notice that you had gained weight? _________________________
What do you feel your weight gain was caused by?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What diets have you tried in the past?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever had any health problems as a result of dieting? Yes No
If yes, what problems?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please list any surgeries you've had:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the
following:
To improve your health, how ready/willing are you to… 1 2 3 4 5
Significantly modify your diet
Take nutritional supplements each day
Keep a record of everything you eat each day
Practice relaxation techniques
Engage in regular exercise/physical activity

Have periodic fitness tests / anthropometric assessments to assess progress
Wellness Goals:
Indicate which health and fitness goals interest you:
❐ Weight management
❐ Increased strength and muscle mass
❐ Increased endurance
❐ Rehabilitation of muscle or joint injury
❐ Advice on supplementation based on my health and dietary practices
❐ Other: (Please describe) ___________________________
Client’s name: ______________ Contact number: _________________
Client’s signature: _________________ Date: ________________
Client’s Guardian signature: _____________________ Date: ________________
(If under 18)
Counsellor’s signature: _________________________ Date: ________________

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CLIENT ASSESSMENT FORM 1

Personal Goals, Motivation and Stage of Readiness

My overall health goals are:

My physical performance goals are:

The biggest challenge(s) to reaching my nutrition goals is/ are:

Do you feel you’ve always had a weight problem? Yes No

What diets have you tried in the past?

If yes, what problems?

Please list any surgeries you've had:

To improve your health, how ready/willing are you to… 1 2 3 4 5

Significantly modify your diet

Take nutritional supplements each day

Keep a record of everything you eat each day

Practice relaxation techniques

Engage in regular exercise/physical activity

❐ Rehabilitation of muscle or joint injury

❐ Advice on supplementation based on my health and dietary practices

❐ Other: (Please describe) ___________________________

Client’s name: ______________ Contact number: _________________

Client’s signature: _________________ Date: ________________

Client’s Guardian signature: _____________________ Date: ________________

(If under 18)

Counsellor’s signature: _________________________ Date: ________________

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Client’s name: Contact number: ___

Client’s signature: _ Date:

Client’s Guardian signature: _____ Date:

Counsellor’s signature: _________ Date: