Name
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First Name
Last Name
Email
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Phone
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Preferred Pronouns
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Please briefly tell me about yourself.
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What does a regular day in your life look like? What are some of your interests or hobbies that you spend time on regularly? What do you do for work?
Why are you seeking support from Anna?
What do you hope to shift or alter through this process?
How do you imagine Anna can help you get there?
How often, if at all, do you currently exercise or engage in a physical activity each week?
Walking, dancing, exercise classes or videos, gardening, etc.
How would you describe your energy levels throughout a typical day?
5 - energized, focused, alert, inspired
4 - generally energized, focused, stable moods
3 - enough energy, focus, and stability
2 - little energy, feelings of overwhelm and high stress
1 - very low energy, overwhelmed, low mood
Fast forward six months—or even six years from now...
1) How would you like your relationship with your body to have changed or evolved? 2) What changes or improvements would you like to see in your nutrition habits? 3) How would you like your mindfulness or mental well-being to have developed? 4) What specific goals would you like to have achieved related to exercise?
What is your primary fitness or movement goal?
Are there any timelines you are working with to achieve this goal? By what date would you like to achieve this goal?
What is your primary motivation for achieving your goal?
How motivated are you about achieving your goal?
5 - very motivated
4 - motivated and taking steps to make change
3 - somewhat motivated and realize I want a change
2 - not very motivated
1 - not motivated
How do you currently feel about exercise or movement? What has it meant to you in the past?
Feel free to share any emotions or stories you feel are relevant.
Have you ever felt stuck or faced challenges with exercise, either currently or in the past? If so, what do you feel is currently, or has been, the biggest barriers to your success?
Can you describe what a typical day of eating looks like for you? This is just to help us understand your current habits so we can work together to support your goals—no judgment at all!
You might include things like:
What time you usually start eating, the types of meals and snacks you have throughout the day, where you typically eat (seated at home, on the go, at work, etc.), any foods you avoid and why, if you have a food budget, whether or not you enjoy cooking, any patterns or routines you tend to follow. This is just about getting a clear picture of your usual day.
Any challenges or frustrations with eating/nutrition right now, or in the past? If so, what do you feel is currently, or has been, the biggest barrier(s) to your success?
Do you have any accessibility needs or physical limitations Anna should be aware of to better support you?
Have you received any recommendations or restrictions from a doctor or healthcare provider regarding physical activity?
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Is there anything specific you’d like Anna to include or avoid in your program?
Do you have any exercise equipment you enjoy using and have regular access to (daily or weekly)?
for example: gym membership, group classes, bands, weights, yoga mat, etc...
Do you travel often, and if so, are you willing or able to stay active while away (e.g., hotel workouts, walks, or using other gym locations), if it aligns with your goals?
What is a typical night of sleep like for you?
How do you currently manage stress, emotions, and challenges during a typical day?
Do you currently have anyone supporting you in working toward your goals (e.g., friends, family, roommate, or training partners)
If yes, how are they involved in your journey?
Do you know how to use Google Docs?
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I do not
I do not, but I'm willing to learn
Yes, I do
Anything else you'd like to add?
