Intake Form

1. My services typically cost $500 - $2000 (?) annually depending on client needs. Right now, most extended health plans in BC don’t cover health coaching. Do you have means/will to pay for it out of pocket?

Yes No

2. Have you been diagnosed with, or are you at risk of developing, a medical condition that threatens your “healthspan” and longevity?

Yes No

3. Are you someone who others would describe as “disciplined”? (definition: able to carefully control the way that you work, live, or behave, especially to achieve a goal … “if you’re disciplined with your money, you could pay off the debt within 6 months”, for example)

Yes No

4. Are you someone who others would describe as “principled”? (definition: based on principles, or (of a person) having good personal standards of behaviour … “she was known among her colleagues as a principled professional”, for example)

Yes No

5. The work involved to join Chris on this journey, just like the health benefits that it will yield, will be over the long term … are you willing to do the work involved?

Yes No

6. Do you consider yourself to have at least another one third of your lifespan left?

Yes No

7. Physically, are you capable of exercising? At the outset of any health program for you, are you capable of, for example, physical exercise such as four half-hour walks a week?

Yes No

8. Would you be willing to wear a wearable fitness tracker such as a Fitbit?

Yes No

9. My coaching is all about incorporating healthy habits that YOU prefer, are comfortable with, and that YOU think would WORK in your current lifestyle. Would you be willing to involve your family in these efforts?

Yes No

10. Do you have 2-3% of each day as personal / free time (30-45 minutes) that you can commit towards your health?

Yes No

11. Do you have a primary care physician (family doctor)?

Yes No

12.Have you seen this doctor for a check-up in the past year?

Yes No

13. Do you drink alcohol 4 nights or more a week? This means even one drink (be honest).

Yes No

14. Do you smoke tobacco or other nicotine products?

Yes No

15. Are you a morning person? (i.e. can you wake up an hour before everyone else in your household?) My coaching doesn't require getting up early, I just want to know so I can create a plan that works for you.

Yes No

16. If you’ve tried sticking to a “reasonably” healthy diet in the past, do the (general) eating habits of others in your household make this challenging?

Yes No

17. Are you a Dad who has young kids, and is looking to turn his health around for the better, to pull himself back from the brink? As a father of three, I have unique insights that a espcially suited for this situation.

Yes No

18. Do you believe that once you’re in your 40’s and 50’s, the trajectory of “normal aging” means slowly getting older, weaker, heavier, more tired, dealing with more pains and aches, and an inevitable steady decline in general health, cognitive abilities and level of fitness?

Yes No

19. Do you believe that, once the “free health ride” of youth is over (which for most is when they hit their 40’s), that we have any control over our own heart health, aging and quality of life?

Yes No

20. Would you be interested in knowing more if you were told that, after a few years of dedicated work in your spare time, that you could look, and feel, younger than your chronological age, and eventually be as biologically functional in your late 70’s as most are in their early 40’s?

Yes No

21. Do you know what our “physical brain” is responsible for, and what language it speaks? (Don’t look this up, just answer yes or no)

Yes No

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