Momentum CoachingIntake Questionnaire Name * First Name Last Name Date of Birth * MM DD YYYY Height * Weight * Ideal Weight (If different from your current weight) Resting Pulse * Do you wear an activity or sleep tracker? * Yes No Only sometimes If yes, please share: 30-Day Average HRV 30-Day Average Respiratory Rate 30-Day Average Sleep Score Score, total sleep hours, and/or deep sleep and REM. 30-Day Average Daily Steps Medical History Do you have any previously diagnosed or treated physical health conditions? * Yes No Please provide details that may be relevant to your ability to participate in the physical activity portion of this program. * Do you have any previously diagnosed or treated mental health conditions? * Yes No Please provide any details that may be relevant to your experience and participation in this program. * Are you currently taking any medications? * Yes No If you answered yes to the question above, please list your medications here. Goals & Objectives What are three specific outcomes you are looking to achieve through Momentum Coaching? * In your opinion, what have been the biggest external obstacles to you achieving these objectives in the past? * In your opinion, what have been the biggest internal obstacles to you achieving these objectives in the past? * Today, do you feel emotionally prepared to create whatever space is necessary in your mind and physical reality to achieve your goals? * Yes No If you find yourself in need of support at any time throughout this program, who could you call for support, and what is their relationship to you? * The Momentum Coaching Program is about personal exploration and growth, which can incredibly rewarding and also very challenging at times. We recommend letting these people know in advance that you may need to lean on them for support. Physical Reality On a scale of 1-10, please rate the following: Body Composition 1 = >30 lbs to lose | 10 = 6 Pack Abs If improved body composition is part of your intention with Momentum, we recommend we recommend a pre and post-program Dexa Scan (find a location near you at www.dexascan.com). Total Weekly Exercise 1 = <30 mins | 10 = >150 mins Food Choices 1 = >50% Unhealthy | 10 = >90% Healthy Sick Days 1 = > 5 days per year | 10 = <1 day per year Life Satisfaction 1 = Unhappy, depressed, anxious | 10 = Happy, joyful, abundant Ambition 1 = Procrastinate | 10 = Taking action everyday Physical Prowess 1 = Ungrounded, uneasy | 10 = Grounded, confident Mental Reality On a scale of 1-10, please rate the following: Mental Performance 1 = Foggy, often unproductive | 10 = Always clear & focused Meditation Practice 1 = <10m per day | 10 = >60m per day Daily Life 1 = Reactive | 10 = Proactive Internal Reality On a scale of 1-10, please rate the following: I experience feelings of shame, guilt, fear and/or anger... 1 = Rarely | 10 = Frequently I experience feelings of appreciation, love and/or gratitude... 1 = Rarely | 10 = Frequently Wholeness 1 = Wounded or lacking | 10 = Whole & overflowing! Intuitive Senses 1 = Unfelt | 10 = Very in tune with my intuition and gut Self-Love 1 = Lacking | 10 = Easily accessible Perspective On a scale of 1-10, please rate the following: Life is happening... 1 = To me | 10 = For me My life is the result of... 1 = Circumstances | 10 = My choices alone My future is... 1 = Uncertain | 10 = Bright and assured Physical Performance Assessments Bolt Score: See instructions here: www.youtube.com/watch?v=KoDSQfVwp8I Dead Hang Test* *Optional. See instructions here: www.youtube.com/watch?v=7QoBFzeRsdA 10-Minute Fan Bike Test* *Optional. See instructions here: www.youtube.com/watch?v=aXfWv4j9_iE If fitness and physical performance is part of your intention with Momentum, we recommend doing all three of the preceding assessments before and after the program. Is there anything else RUNGA should know about you before we start this program? Thank you! We’re excited to support you.“Everything in your life is there as a vehicle for your transformation. Use it!” - Ram Dass
