Health Coach Client Intake Form Template and Examples

Health coach intake forms are essential tools for gathering important information about new clients. The initial assessment typically includes the following main categories of information to request and the reasons why:

1. Introduction: This section sets the stage for the coaching relationship, including an overview of what to expect from the sessions and any confidentiality agreements. Basic details like name, address, and contact information are essential for identification and communication purposes.
2. Health History: Collects detailed information about the client’s past and current health conditions, surgeries, medications, and family medical history. This acts as a health record that helps a coach understand the client’s overall health status and potential risks.
3. Lifestyle Habits: Includes questions about daily routines, diet, exercise, sleep patterns, and stress levels. Understanding these habits helps tailor personalized health plans for clients.
4. Goals and Motivations: Identifies the client’s health and wellness goals, their motivations for seeking coaching, and any specific outcomes they wish to achieve. This is key to setting realistic and achievable objectives for the coaching process.
5. Challenges and Obstacles: Highlights any barriers or challenges the client faces in achieving their health goals, such as time constraints, lack of resources, or emotional hurdles. This helps in creating realistic and supportive strategies.
6. Assessment of Current Health Status: This may include measurements like weight, BMI, blood pressure, and other relevant metrics to provide a baseline snapshot of the client’s current health status.
7. Consent and Confidentiality: Ensuring informed consent and understanding of confidentiality agreements is essential for ethical and legal compliance, as well as building trust with the client.

Using intake form templates offers numerous benefits for service-based businesses, healthcare providers, and other professionals. Here are some key advantages:

• Time Efficiency: Intake form templates streamline the process of collecting client information, significantly reducing the time needed to gather and organize data manually. This allows professionals to focus more on their core tasks.
• Accuracy and Consistency: Templates ensure that the same information is consistently collected from all clients, minimizing the risk of errors and omissions. This leads to more accurate and reliable data, which is crucial for making informed decisions.
• Improved Organization: Using standardized forms helps in better organizing and managing client information. This facilitates easier retrieval and review of data, enhancing overall workflow and efficiency.

How Textexpander Can Help

TextExpander is a powerful tool that can greatly assist health coaches in managing their intake forms and enhancing their overall efficiency. Here are some ways TextExpander can help:

• Enhanced Client Experience: Well-structured intake forms can make the onboarding process smoother and more efficient for clients. By simplifying the information-gathering process, clients feel more at ease and are more likely to engage positively with the service.
• Automated Data Collection: Utilizing digital intake forms can automate data entry, reducing the potential for manual errors. This ensures that all necessary information is captured accurately and can be easily accessed and reviewed when needed.
• Better Compliance and Documentation: Intake forms help ensure that all required information is documented properly, which is crucial for legal and regulatory compliance. This can be particularly important in healthcare and other regulated industries where thorough documentation is essential.

Intake Form Example 1: Jane Doe

Personal Information
– Full Name: Jane Doe
– Date of Birth: 1985-03-12
– Gender: Female
– Contact Information: (Phone) 555-1234, (Email) jane.doe@example.com
– Emergency Contact: John Doe (Husband), 555-5678

Health History
– Current Medications: None
– Allergies: Penicillin
– Past Surgeries/Medical Conditions: Appendectomy (2010)
– Family Health History: Mother – diabetes, Father – hypertension
– Recent Health Concerns: Frequent headaches, fatigue

Lifestyle Habits
– Dietary Habits: Vegetarian, three meals a day with occasional snacks
– Exercise Routine: Yoga twice a week, walks 30 minutes daily
– Sleep Patterns: 7 hours per night, occasionally disrupted
– Stress Levels: High due to work pressure
– Substance Use: Social alcohol use

Goals and Motivations
– Primary Health Goals: Increase energy levels, improve overall fitness
– Motivation for Seeking Health Coaching: Desire to maintain a healthy lifestyle and manage stress
– Specific Outcomes Desired: Consistent energy throughout the day, enhanced physical fitness

Challenges and Obstacles
– Barriers to Achieving Goals: Limited time due to a busy work schedule
– Previous Attempts at Health Improvement: Joined a gym but lacked consistency

Consent and Confidentiality
– Consent to Share Information: Yes
– Understanding of Confidentiality: Yes

Intake Form Example 2: Mark Smith

Personal Information
– Full Name: Mark Smith
– Date of Birth: 1978-09-23
– Gender: Male
– Contact Information: (Phone) 555-8765, (Email) mark.smith@example.com
– Emergency Contact: Emily Smith (Wife), 555-4321

Health History
– Current Medications: Atorvastatin (for cholesterol)
– Allergies: None
– Past Surgeries/Medical Conditions: ACL reconstruction (2015)
– Family Health History: Father – heart disease, Mother – osteoarthritis
– Recent Health Concerns: Weight gain, joint pain

Lifestyle Habits
– Dietary Habits: High-protein diet, frequent snacking on processed foods
– Exercise Routine: Occasional gym visits, no regular routine
– Sleep Patterns: 6 hours per night, often restless
– Stress Levels: Moderate, related to family and work
– Substance Use: None

Goals and Motivations
– Primary Health Goals: Lose weight, reduce joint pain
– Motivation for Seeking Health Coaching: Improve health to play more actively with children
– Specific Outcomes Desired: Weight loss of 20 pounds, pain-free mobility

Challenges and Obstacles
– Barriers to Achieving Goals: Lack of motivation, inconsistent exercise habits
– Previous Attempts at Health Improvement: Tried dieting, but results were temporary

Consent and Confidentiality
– Consent to Share Information: Yes
– Understanding of Confidentiality: Yes

Intake Form Example 3: Sarah Johnson

Personal Information
– Full Name: Sarah Johnson
– Date of Birth: 1992-06-15
– Gender: Female
– Contact Information: (Phone) 555-4567, (Email) sarah.johnson@example.com
– Emergency Contact: Michael Johnson (Brother), 555-2345

Health History
– Current Medications: Levothyroxine (for hypothyroidism)
– Allergies: None
– Past Surgeries/Medical Conditions: None
– Family Health History: Grandmother – breast cancer, Uncle – stroke
– Recent Health Concerns: Anxiety, digestive issues

Lifestyle Habits
– Dietary Habits: Gluten-free diet, eats three main meals with snacks
– Exercise Routine: Runs 3 times a week, occasional pilates
– Sleep Patterns: 8 hours per night, generally good quality
– Stress Levels: High due to personal life events
– Substance Use: None

Goals and Motivations
– Primary Health Goals: Manage anxiety, improve digestion
– Motivation for Seeking Health Coaching: To find natural ways to cope with stress and improve gut health
– Specific Outcomes Desired: Reduced anxiety symptoms, regular digestion

Challenges and Obstacles
– Barriers to Achieving Goals: Stress from recent life changes, lack of knowledge about gut health
– Previous Attempts at Health Improvement: Tried meditation and probiotics, with limited success

Consent and Confidentiality
– Consent to Share Information: Yes
– Understanding of Confidentiality: Yes