Health Coaching Pre-Consultation Questionnaire

Please include details about your:

• Occupation (including whether your work is mostly sedentary or physically active)

• Daily routine and lifestyle habits

• Physical activity levels and any regular exercise

• Hobbies or interests

• Family or home life that may impact your schedule or routines

• Any dietary preferences, allergies, intolerances, or specific requirements

• Current health status, including any medical conditions, medications or ongoing concerns

We’d love to understand what you’re hoping to achieve from this programme. Please share your short-term and long-term goals. If possible, try to include SMART objectives (Specific, Measurable, Achievable, Relevant, and Time-bound), such as:

• “Lose 5kg over the next 12 weeks”

• “Improve sleep quality by getting 7–8 hours of rest most nights”

• “Build strength by attending 3 gym sessions per week”

This helps us create a plan that is tailored and realistic for you.

Include as much detail as possible about:

• Meal times (e.g. breakfast, lunch, dinner, snacks)

• Types of food and drink consumed

• Portion sizes (approximate amounts or measurements if known)

• Fluid intake throughout the day (include water, tea, coffee, soft drinks, etc.)

This will help us understand your current eating habits and identify areas we can support you with.

You can send us a food diary if you would like to enquiries@thefamilychemist.co.uk.

We’d love to understand your expectations so we can support you in the best possible way.
Please share what you’re looking for from this programme — for example:

• Guidance on weight loss or healthy eating

• Support with motivation and accountability

• Help building sustainable habits

• Advice tailored to your medical needs or lifestyle

The more you share, the better we can personalise your journey.

To help us better understand your overall health, please provide some information about your menstrual history:

• Is your cycle regular or irregular?

• Are you currently experiencing perimenopause, menopause, or postmenopause?

• If applicable, please share any symptoms or concerns related to your cycle or hormonal health.

If this does not apply to you, please enter “N/A” and click ‘Done’.

Please include details such as:

• How often you exercise each week

• The type of training or activities you do (e.g. walking, gym workouts, running, yoga, resistance training, etc.)

• The duration and intensity of each session

• Any challenges or limitations you face when exercising

This helps us understand your starting point and how we can best support your goals.

If yes, please tell us:

• Who it was from (e.g. GP, dietitian, nutritionist, coach)

• What the focus was (e.g. weight loss, managing a condition, general health)

• Whether you found it helpful or effective. What could they have done better?

This helps us understand your past experiences and how we can build on them.

We ask this to help determine whether calorie tracking using an app like MyFitnessPal may be suitable for you.
If you haven’t used a calorie-tracking app before, don’t worry — we’re here to guide you through it and offer support if you choose to give it a try.